■RJ4y  SmvS 

Columbta  (MnitJer^itp 
tntI)pCitpoflfttJg(jrk 

College  of  ^l)psiician£f  anb  burgeons; 
llifararp 


Gifiof 

Dr.  Jerome  P  Webster 


A  TREATISE 


THE    DISEASES 


INFANCY   AND   CHILDHOOD, 


BY 

J.    LEWIS    SMITH,    M.D., 

CLINICAL  PROFESSOR  OF  DISEASES  OF  CHILDREN  IN  BF.LLEVUE  HOSPITAL  MEDICAL  COLLEGE;   PHVSICIAN  TO 

CHAEIIY  HOSPITAL  ;   PHYSICIAN  TO  THE  N.  Y.   FOUNDLING  ASYLUM  ;   CONSULTING  PHYSICIAN  TO 

■"IE  N.  Y.  INFANT  ASYLUM  ;    CONSULTING  PHYSICIAN  TO  THE  CLASS  OF  CHILDEEN'S 

DISKASES,  BUKEAU  FOB  THE  RELIEF  OF  THE  OUTDOOR  POOR,  BELLEVUBi 


SIXTH  EDITION.  THOROUGHLY  REVISED. 


WITH    FORTY    ILLUSTRATIONS. 


r  H  I  L  A  D  E  L  P  II I  A  ; 


LEA   BROTHERS    &  CO. 

1886, 


Entered  according  to  the  Act  of  Congress,  in  the  year  1885,  hy 

LEA    BROTHERS    &    CO., 
In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


nilLAPELPHIA  : 
D  0  R  N  A  N  ,      r  R  I  N  T  F.  R, 


PREFACE  TO  THE  SIXTH  EDITION. 


In  preparing  the  Sixth    Edition,  the  author  has    revised  the  text 

to  such    an    extent,    that    a    considerable  part    of    the  book    may  be 

considered    new.       Such    thorough    revision    was    required    by    the 

advancement  of  our  knowledge  of  the  diseases  of   children  since  the 

last    edition    was    issued.      Some    of  the    important   maladies    in    the 

book   have    been    entirely   rewritten,    such    as    cerebro-spinal   fever, 

scarlet  fever,  pseudo-membranous  croup,  and  infantile  diarrhoea,  and 

the  treatment  of  many  of  the  diseases  has  been  revised.     The  index 

has  been   prepared  by  J.  Lewis  Smith,  Jr..  physician  to  the  Class  of 

Children's    Di.seases,  in    tlie    Bureau  for  the    Relief  of   the    Outdoor 

Poor,  Bellevue. 

J.  L.  S. 

No.  02  Wkst  56th  St.,  Nkw  York, 
January  1,  1886. 


(  iii  ', 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseondiseaOOsmit 


PREFACE  TO  THE  FIFTH  EDITION. 


The  constant  endeavor  of  the  author,  as  successive  editions  of  this 

treatise  have  been  called  for,  has  been  to  make  it  more  useful  to  the 

medical  student  and  to  the  physician  in  his  daily  practice.     He  has 

avoided  discussion  of  theories,  except  as  they  influence  practice,  -while 

he  has  devoted  more  space  to  the  therapeutics  of  the  various  diseases. 

He  has  been  stimulated  to  this  by  constant  intercourse  with  physicians, 

so  as  to  be  able  to  appreciate  their  wants,  and  by  letters  of  inquiry 

sent  by   physicians,  which,   for  the  most   part,   relate  to   matters   of 

treatment. 

J.  L.  S. 

No.  227  West  40th  St.,  Nkw  York, 
September  16,  1881. 

(T) 


LIST  OF  ILLUSTRATIONS, 


no. 

1.  Case  of  deformity  of  foetus  due  to  injury  of  mother 

2  Milk  globules      .         .  • 

3.  Colostrum- corpuscles  ...... 

4.  Case  of  meningocele   ...... 

5.  Case  of  rachitic  deformity  of  thorax  and  abdomen 

6.  Skeleton  of  rachitic  infant  .... 

7.  Head  of  rachitic  infant       .....' 

8.  Rachitic  spinal  curvature  in  adult 

9.  Cases  of  rachitic  deformity  of  liead  and  ribs 

10  Deformity  of  chest  in  rachitis    .... 

11,  12,  13.  Rachitic  deformity  of  pelvis    . 

14,  15.  Rachitic  deformity  of  the  femur 

16,  17.   Rachitic  deformity  of  the  tibia  and  fibula    . 

18.  Scrofulous  dactylitis    ...... 

19.  Case  of  strumous  inflammation  of  the  joints 

20.  Case  of  bronchial  phthisis  ..... 

21.  Bacillus  tuberculosis   ...... 

22.  Case  of  dactylitis  syphilitica       .... 
'2?j.  Development  of  the  teeth  in  syphilis 

24.  Deformity  from  pertussis    ..... 

25.  Position  in  cerebro-spinal  fever 

26.  Case  of  rheumatic  deformity       .... 

27.  Case  of  accjihalus 

28.  Case  of  congenital  hydrocephalus 

29.  Case  of  congenital  hydrocf'phalus 

30.  Outline  of  head  in  acquired  hydroce]'lialus 

31.  Case  of  facial  paralysis       ..... 

32.  Case  of  pseudo-hypertrophic  paralysis 

33.  Case  of  spina  bifida    ...... 

34.  Microscopic  apf)earance  in  embolismal  pneunioiiia 

35.  Case  of  gangrene  of  mouth         .... 
86.  Tntusjusreption  .  . 

37  to  40.  Acaruo  bcabiei 


PAGZ 

22 
34 
34 

75 
101 
107 
120 
121 
122 
1-23 
124 
125 
126 
129 
147 
1G2 
173 
183 
184 
333 
359 
401 
416 
443 
445 
451 
539 
541 
548 
Oil 
075 
791 
854 


{   ^-'i  ) 


CONTENTS. 


PAET   I. 

CHAPTER   I. 

PAGK 

Infancy  AND  Childhood ^        .        .^        .        .17 

CHAPTER   II. 
Care  of  the  Mother  in  Pregnancy 19 

CHAPTER  III. 
Mortality  of  Early  Life:  Its  Causes  and  Prevention  .         .         .         .23 

C  H  A  P  T  E  R   I  V. 

Weight,  Growth,  Lactation 28 

Hindrances  to  Lactation  and  Physical  Conditions  Rendering  it  Improper — 
Colostrum — Human  Milk — Modification  of  Milk  in  Consequence  of  the 
Diet — Modification  of  Milk  from  its  Retention  in  the  Breast — Modifica- 
tion of  Milk  by  Age  and  by  Mental  Impressions — Modification  of  Milk  by 
the  Catamenial  Function,  Pregnancy,  and  Other  Causes — Differences  in 
Suckling  Women  as  Regards  Quantity  and  Quality  of  Milk — Scantiness 
of  Milk;  its  Causes  and  Treatment. 

C  H  A  P  T  E  ]i   V. 
Selection  of  a  Wetnurse 44 

CHAPTER  yi. 
CouR.SK  OF  Lactation — Weaning 48 

CHAPTER  VI  L 
Quantity  OF  Food  Required  IN  Infancy  and  Childhood  .        .        .61 

CHAPTER   VIII. 
Artificial  Fkeding  ...........     6" 

CH  A  PTER    IX. 

Bathing,  Clothing,  Slkkp,  E.xercise    ......  .6*3 

Clothing — Sleep — Exercise. 

(ix) 


CONTENTS. 


CHAPTER   X. 

PAGE 

Diseases  of  the  New-born 71 

Apnoea  (Asphyxia)  Neonati  —  Caput  Siiccedaneum  —  Cephalaniiatoma  — 
Meningocele,  Encephalocele,  Hydrencephalocele. 

CHAPTER   XI. 
Ophthalmia  Neonati     ,......,..,       77 

CHAPTER   XII. 

Diseases  of  the  Umbilicus 82 

Thrombosis  and  Phlebitis  of  the  Umbilical  Vein,  Septicajmia  of  the  New- 
born— Inflammution  and  Ulceration  of  Umbilicus — Umbilical  Granula- 
tions or  Fungus. 

CHAPTER   XIII. 
Umbilical  Hemorrhage 87 

CHAPTER   XIV. 

Diagnosis  of  Infantile  Diseases 90 

General  Observations — Features,  External  Appearance  of  Head,  Trunk, 
and  Limbs  in  Disease — Attitude — Movements — The  Voice — Respiratory 
System — Circulatory  System — Animal  Heat — Digestive  System — Ner- 
vous System. 

CHAPTER   XV. 
Therapeutics 103 


PART   II. 

CONSTITUTIONAL  DISEASES. 

SECTION  I. 

DIATHETIC  DISEASES. 

CHAPTER   I. 

Rachitis 105 

Frequency  of  Rachitis — Age  at  which  Rachitis  Occurs — Causes  of  Rachitis 
— Artificial  Production  of  Rachitis — Anatomical  Characters  of  Rachitis 
— Symptoms  of  Rachitis — Complications  and  Sequelre  of  Rachitis — Diag- 
nosis of  Rachitis — Prognosis  of  Rachitis — Treatment  of  Rachitis. 

CHAPTER  II. 


Scrofula 

Strumous  Ophthalmia. 


135 


CONTENTS.  XI 

CHAPTEK    III. 

PAGE 

Tuberculosis 153 

CHAP  TEE   IV. 
Syphilis 177 

SECTION  II. 

EEUPTIVE  FEVEKS. 

CHAPTER   I. 

Measles 188 

CHAPTEPv   II. 
Scarlet  Feter „     197 

CHAPTEPv   III. 

ROTHELN o  .       265 

CHAPTER   IV. 
Variola — Varioloid 274 

CHAPTER  V. 

Vaccinia 283 

Subsequent  Vaccinations — Protection  from  Vaccination — Revaccination — 
Selection  of  Virus 

CHAPTER   VI. 
Varicella       .  293 

SECTION  III. 

NON-ERUPTIVE  CONTAGIOUS  DISEASES. 
CHAPTER   I. 

Diphtheria 295 

Pertussis 

CHAPTER   II. 
Parotiditis 339 


Xll  CONTENTS. 

SECTION  IV. 

OTHER  GENERAL  DISEASES. 

CHAPTEK   I. 

PAGE 

Intermittent  Fever .     342 

CHATTEK   II. 
Remittent  Fever 347 

CHAPTER   III. 
Typhoid  Fever 348 

CHAPTER   IV. 
Cerebro-spinal  Fever 358 

CHAPTER   V. 
Acute  Rheumatism 398 

CHAPTER  VI. 
Erysipelas .    404 


PAET  III. 

SECTION  I. 

DISEASES  OF  THE  CEREBRO-SPINAL  SYSTEM. 

CHAPTER   I. 

AcEPHALUs — Anencepiialtjs 415 

CHAPTER   IL 

Imperfect  Brain .     417 

Microcephalus — Atrophy  of  Brain 

CHAPTER   III. 
Hypertrophy  of  Brain .     420 

CHAPTER   IV. 
Thrombosis  in  the  Cranial  Sinuses  (Phlebitis) .,     424 

CHAPTER  V. 
Congestion  of  the  Bkain .        »        .    429 


CONTENTS.  xiii 

CHAPTER    VI. 

PAGE 

Intracranial  Hemorrhage  (Meningeal  Hemorrhage;  Cerebral  Hem- 
orrhage)  433 

CHAPTER   VII. 
Congenital  Hydrocephalus 442 

CHAPTER   YIII. 
Acquired  Hydrocephalus 449 

CHAPTER   IX. 
Meningitis,  Tubercular  and  Non-tubercular 452 

CHAPTER  X. 
Spurious  Hydrocephalus 470 

CHAPTER   XL 
Eclampsia 476 

CHAPTER   XII. 
Tetanus  Infantum 485 

CHAPTER   XIII. 
Internal  Convulsions 504 

CHAPTER   XIV. 
Chorea 512 

CHAPTER   XV. 
Infantile  Paralysis 528 

CHAPTER   XVI. 

Facial  Paralysis 538 

Paralysis  with  Pseudo-hypertrophy. 

CHAPTER   XVII. 

Diseases  of  the  Spinal  Cord  AND  ITS  Coverings 544 

Congestion  of  tlje  Spinal  Cord  and  its  Membranes. 

CHAPTER   XVIII. 
Spina  Bifida 547 

CHAPTER   XIX. 
Vertebral  Caries 651 


XIV  CONTENTS. 

SECTION  II. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 
CHAPTER   I. 

PAGE 

CORYZA 556 

CHAPTER   II. 

Catarrhal  Laryngitis 559 

Spasmodic  Laryngitis. 

CHAPTER   III. 
Membranous  Croup;  Diphtheritic  Croup;  True  Croup         .        .        .     567 

CHAPTER  IV. 
Bronchitis 598 

CHAPTER  V. 
Atelectasis 605 

CHAPTER  VL 
Pneumonitis ,        .        .     609 

CHAPTER   VI  L 

Pleuritis 622 

Nervous  Cough. 

SECTION  III. 

DISEASES  OF  THE  DIGESTIVE  APPARATUS. 

CHAPTER   I. 

Simple  Stomatitis,  Ulcerous  Stomatitis,  Follicular  Stomatitis        .     663 
Simple  or  Catarrhal  Stomatitis — Ulcerous  Stomatitis — Aphthous  Stomatitis. 

CHAPTER   II. 
Thrush 669 

CHAPTER  III. 
Gangrene  of  the  Mouth .     673 

CHAPTER   IV. 

Dentition 680 

Second  Dentition. 

CHAPTER   V. 
Catarrhal  Pharyngitis,  Peri-pharynoeal  Abscess,  (Esophagitis      .     687 


CONTENTS.  XV 


CHAPTEK   VI. 

PAGE 

Indigestion,  Congestion  of  Stomach,  Gastritis,  Follicular  Gastritis, 

Diphtheritic  Gastritis,  Post-mortem  Digestion,  Softening  .  697 

Congestion  of  the  Stomach — Gastritis — Follicular  Gastritis — Diphtheritic 
Gastritis — Post-mortem  Digestion — Softening. 

CHAPTEE   VII. 

DiARRHCEA 713 

Non-inflammatory  Diarrhoea. 

CHAPTEK   VIII. 

Intestinal  Catarrh  of  Infancy  (Entero-colitis)  .        .         .  718 

Cholera  Infantum,  or  Ciioleriform  DiarrhcEa. 

CHAPTEK   IX. 
Enteritis  and  Colitis  in  Childhood ,     747 

CHAPTER   X.' 
Constipation 750 

CHAPTER   XL 
Intestinal  Worms .     765 

CHAPTER  XII. 
Gastro-intestinal  Hemorrhage 781 

CHAPTER   XIII. 

Intussusception  787 

Intussusception  without  Symptoms — Intussusception  with  Symptoms — In- 
tussusception in  the  Small  Intestines — Intussusception  in  Large  Intes- 
tines. 

SECTION  IV. 

DISEASES  OF  THE  GENITO-URINARY  ORGANS. 

Uric  Acid  Infarctions — Enuresis — Calculi,  Dysuria,  Cryptorciiia — Vulvitis    .     810 

SECTION  V. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

CHAPTER    I. 

Cyanosis 823 

Literature  of  Cyanosis — Sex — Causes  of  the  Malformations — Sym|itom.i — 
Prognosis — Mnde  of  Death — Modes  of  Compensation — Morbid  Anatomy 
— Theories  Relating  to  the  Etiology  of  Cyanosis — Treatment. 


xvi  CONTENTS. 

SECTION  VI. 

SKIN  DISEASES. 
CHAPTER   I. 

PAGE 

Erythematous  Diseases       ..........     840 

Ervtheuui — Koseola — Urticaria. 

CHAPTEE   II. 

Papular  Diseases .....     846 

Strophulus. 

CHAPTER   III. 

Eczema ....    847 

Scabies    .......  .        .        .        .        -    854 


THE 


DISEASES  OF  CHILDREN. 


PART  I. 


CHAPTEE    I. 

IXFAXCY  AND  CHILDHOOD. 

Infancy  nml  cliildliood  are,  in  certain  respects,  the  most  important 
and  interesting  periods  of  life.  To  the  physiologist  they  arc  especially 
interesting,  hecause  they  are  the  periods  of  development  and  of  greatest 
functional  activity;  to  the  pathologist,  because  in  them  many  diseases 
occur  which  are  rarely  or  never  observed  in  the  other  periods,  or  which 
present  in  these  periods  peculiar  features;  to  the  physician  and  vital 
statistician,  because  in  them  there  are  the  greatest  amount  of  sickness 
and  larfrest  number  of  deaths. 

Infancy  extends  from  birth  t(>  the  age  of  two  and  a  half  years,  or 
till  the  completion  of  first  dentition.  In  infancy  the  organs  are  delicately 
organized,  containing  a  large  proportion  of  water,  and  hence  are  easily 
injured.  In  tliis  period  the  brain  \fi  rapidly  developed — more  so  than 
any  other  organ;  animal  matter  predominates  in  the  bones;  the  arteries 
are  relatively  large,  the  muscles  small;  the  superficial  veins  are  small. 
Fat  is  absent  from  the  interior  of  the  body,  but  abundant,  in  well- 
nourished  infants,  underneath  the  integument.  The  skin  is  delicate, 
and  its  temperature  not  much  below  that  of  the  blood.  At  birth  it  has 
a  reddish  hue,  and  is  covered  with  soft,  fine  hairs  (lanugo).  The  reddish 
hue  gradually  fades  into  the  healthy  tint  of  infancy,  and  the  hairs  fall 
out.  In  the  first  two  months  the  sweat-glands  have  little  functional 
activity,  sensible  perspiration  being  quite  rare.  Subsequently  perspira- 
tion is  freer,  and  in  certain  diseased  states  (rachitis,  etc.)  is  abundant. 
The  sebaceous  glands  in  the  first  half  of  infancy  are  active,  particularly 
upon  the  seal]),  j)roducing  often  a  ])ale  yellow  incrustation,  consisting  of 
sebaceous  matter  and  ejjidermic  cells. 

The  secretions  from  the  mucous  surfaces  commence  at  an  early  period. 
At  birth  the  surface  of  the  digestive  tube  is  covered  with  more  or  less 
mucus,  often  in  considerable  quantity.  The  meconium  is  not  considered, 
as  formerly,  to  be  a  product  of  intestinal  secretion.     It  consists  of  flat 

■      2  (17) 


18  IXFANCY    AND    CHILDHOOD. 

epithelial  cells,  fine  hairs,  oil-globules,  crystals  of  cholesterin,  and 
brownish  or  yellowish  masses  of  coloring  matter  probably  from  the 
liver.  It  is  supposed  that,  with  the  exception  of  the  coloring  matter, 
the  meconium  is  derived  mainly  from  the  amniotic  fluid  which  the  foetus 
has  swallowed. 

The  most  wonderful  change  occurring  in  the  system  at  birth,  through 
the  exigencies  of  the  new  life,  is  that  in  the  circulation.  The  flow  of 
blood  being  interrupted,  thrombi  form  in  the  umbilical  vein  and  arteries, 
and  in  the  ductus  arteriosus  and  ductus  venosus,  and  these  vessels 
gradually  atrophy,  becoming  finally  shrivelled  but  permanent  cords. 
1  have  many  times  at  autopsies  removed  the  plug  from  the  ductus 
arteriosus  when  death  had  occurred  as  late  as  the  third  week.  The 
foramen  ovale  closes  sloAvly.  I  have  ordinarily  found  it  open  till  near 
the  end  of  the  first  half  year,  but  the  valve  covers  fully  the  aperture, 
so  that  there  is  no  detriment  to  the  circulation.  Both  the  pulse  and 
respiration  are  more  frerpient  during  infancy  than  childhood,  and  are 
more  accelerated  by  moral  and  physical  causes. 

The  stomach  has  a  smaller  relative  size  and  eniesis  is  more  readily 
caused  than  in  the  adult.  The  liver  is  large,  occupying  at  birth  nearly 
half  of  the  abdominal  cavity,  but  it  grows  smaller  in  successive  months. 
The  appetite  is  good  and  digestion  active,  so  tlmt  hunger,  Avhen  appeased, 
soon  returns.  The  thymus  gland,  at  birth  about  the  size  of  an 
expanded  lung,  slowly  atrophies,  but  it  does  not  totally  disappear 
till  after  infancy. 

The  kidneys,  distinctly  lobulated  at  birth,  gradually  change  their 
form,  so  as  to  present  in  the  last  part  of  infancy  nearly  the  shape  of 
the  organ  in  the  adult.  The  renal  secretion  commences  early,  even 
before  birth.  The  kidneys  seldom  undergo  degenerative  changes  as  in 
the  adult,  but  they  are  liable  to  congestion.s  and  inflammations. 
During  the  first  month,  and  especially  tlie  first  fortnight,  crystals  of 
uric  acid,  and  the  urates,  are  often  found  in  the  urine,  in  a  state  of 
apparent  health,  causing  more  or  less  fretfulness  in  their  elimination, 
staining  the  diaper,  and  not  infrequently  being  arrested  in  the  tubules 
of  the  pyramids,  where  they  can  be  seen  as  pink-colored  spots  or  lines 
(uric  acid  infarction).  These  deposits  of  uric  acid  and  the  urates  may 
even  occur  in  the  foetus,  producing  obstruction  and  inflammation  of  the 
renal  tubes.  Congenital  cystic  degeneration  of  the  kidneys  is,  in  the 
opinion  of  Virchow,  due  to  them.  In  early  infancy  the  senses  are 
imperfectly  developed,  the  eyes  being  attracted  only  by  bright  objects, 
and  the  sense  of  hearing  aff'ected  only  by  loud  noises.  Sleep  is  the 
normal  state  in  the  first  weeks  of  life;  as  the  age  of  the  infant 
increases,  less  and  less  sleep  is  required ;  but  the  oldest  infants  need 
more  than  children,  and  several  hours  more  than  adults. 

The  new-born  infant  is  apparently  destitute  of  mental  faculties.  It 
seeks  the  breast  by  instinct,  and  it  exhibits  no  perception  or  reflection. 
The  loud  cries  with  which  it  commences  its  existence  are  not  from 
anger  or  suffering;  they  appear  to  be  normal,  like  the  act  of  nursing, 
and  providentially  designed,  in  order  to  expand  the  lungs.  It  is  not 
till  the  close,  or  near  the  close,  of  the  first  month,  that  the  gray  sub- 
stance of  the  brain  begins  to  appear — the  probable  seat  of  the  mind, 


CARE  OF  THE  MOTHER  IX  PREGXAXCY.        19 

and  the  source  of  all  mental  phenomena.  Perception  and  curiosity  are 
earl}'^  manifested.  The  infant,  as  Edmund  Burke  has  remarked,  is  con- 
stantly seeking  new  objects  for  its  amusement,  rejecting  old  playthings 
for  such  as  possess  more  novelty.  Reflection,  a  higher  faculty  of  tiie 
mind,  appears  at  a  later  period.  The  mind  and  the  bodily  organs  in 
infancy  are,  in  a  high  degree,  impressionable.  Anger  is  excited  by 
trivial  causes,  but  is  easily  appeased;  and  the  various  functions  in  the 
system  are  disturbed  by  agencies  Avhich  in  youth  or  manhood  "would 
have  no  appreciable  effect. 

Childhood  extends  from  infancy  to  the  age  of  fifteen  years  or 
puberty.  It  is  a  period  of  great  physical  activity,  and  of  rapid  growth. 
The  functions  of  the  various  organs  are  performed  with  more  modera- 
tion than  in  infancy,  and  are  less  frequently  deranged.  The  volume 
of  the  brain  continues  to  increase  rapidly,  and  it  becomes  firmer  than 
in  infancy.  It  is  estimated  that  by  the  seventh  year  the  weight  of  this 
organ  has  doubled.  The  mind  now  exerts  a  controlling  influence  over 
the  actions  of  the  individual.  The  digestive  organs  have  changed,  so 
that  solid  food  is  required.  JNIost  of  the  glandular  organs  are  less 
active  than  in  the  greater  part  of  infancy,  and  some  of  them,  as  the  liver, 
are  relatively  smaller.  The  pulse  and  respiration  gradually  become  less 
frequent  as  the  child  advances  in  age. 


CHAPTER    II. 

CARE  OF  THE  MOTHER  IX  PREGXANCY. 

The  frequency  of  miscarriages  and  still-births,  and  the  large  number 
of  ill-formed  and  puny  infants,  born  to  a  precarious  and  short  existence, 
render  imperative,  on  the  part  of  the  mother,  a  strict  observance  of  the 
laws  of  health,  and  an  avoidance  of  all  exciting  or  perturbating  influences 
during  the  time  when  the  foetus  is  being  developed.  The  diet  should 
be  plain  and  easily  digested,  but  nutritious.  There  is  often  a  craving 
in  pregnancy  for  unusual  articles  of  food.  These  may  sometimes  be 
allowed  within  certain  limits,  provided  that  they  arc  such  as  do  not 
derange  the  stomach.  Meats  and  animal  broths,  together  with  vege- 
tables and  farinaceous  food,  should  constitute  the  ordinary  diet,  and 
should  be  taken  at  regular  intervals. 

Daily  exercise,  never  violent,  but  modei-ato  and  gentle,  is  requisite. 
No  exercise  is  better,  none  safer  and  more  likely  to  contriljute  to  cheer- 
fulness and  healthy  functional  activity  of  the  organs,  than  the  ordinary 
liousehold  duties.  Lifting  heavy  weights,  or  work  which,  like  washing 
and  ironing,  causes  great  and  continued  action  of  the  abdominal  muscles, 
should  be  avoided.     Such  e,\,ercise  is  highly  injurious,  and  rs  apt  to 


20        CARE  OF  THE  MOTHER  IX  rREaXAXCY, 

produce  premature  labor.  Exercise  in  tlie  open  air,  on  foot,  or  by  an 
easy  conveyance,  conduces  to  the  health  of  tiie  mother  and  the  growth 
and  deveh)pment  of  the  ftxitus.  On  the  other  luind,  rii])id  riding  over 
rough  roads  is  one  of  the  most  dangerous  modes  of  exercise.  It  has 
been  known  to  destroy  the  foetus,  which  up  to  that  time  liad  been  ap- 
parently vigorous.  AVHien  such  a  result  occurs,  there  is  probably  more 
or  less  detachment  of  the  placenta. 

It  being  a  matter  of  the  utmost  importance  that  the  health  of  the 
mother  should  continue  good  during  gestation,  any  disease  Avhich  she 
may  have  in  this  period,  and  Avliich  ailects  her  nutrition  or  the  character 
of  her  blood,  should  be  promj)tiy  cured  if  practicable,  and  with  the 
least  possible  reduction  of  the  vital  powers.  Intermittent  fever,  occur- 
ring during  gestation,  siiould  never  be  allowed  to  continue.  It  seriously 
retards  foetal  development,  and  may  produce  miscarriage.  Unless  it  be 
controlled  by  proper  measures,  the  offspring,  though  born  at  term,  is 
puny  and  emaciated.  Sypliilis,  in  the  pregnant  woman,  also  rerpiires 
treatment.  This  disease,  readily  transmitted  from  the  mother  to  the 
foetus  through  the  ovum  or  the  uterine  circulation,  may  be  eradicated 
by  .anti-syphilitic  treatment  of  the  mother,  or  at  least  so  modified  that 
the  infant  is  born  vigorous  and  healthy. 

The  pregnant  woman  should  avoid  ail  causes  of  undue  mental  excite- 
ment. This  is  almost  as  necessary  as  the  avoidance  of  great  physical 
exertion.  There  is,  during  prcgnr.ncy,  unusual  susceptibility  to  mental 
impressions,  and  this  should  be  borne  in  mind  not  only  by  the  woman 
herself,  but  by  those  Avho  associate  with  her. 

Strong  emotions,  whether  of  joy,  sorrow,  or  anger,  affect  primarily 
the  nervous  system,  but  indirectly  most  of  the  organs  of  the  body. 
Observations  have  lono-  establislied  the  fiict  that  such  emotions  influence 
the  state  and  functions  not  only  of  the  digestive  and  glandular,  but 
muscular  organs,  as  the  heart  and  uterus.  Physicians  are  familiar  Avith 
cases  in  Avhich  vivid  mental  impressions  produced  uterine  contractions, 
and  even  miscarriage,  or  have  disturbed  the  catamenial  function. 
Therefore,  the  associations  and  cares  of  pregnant  women  should  be  such 
as  conduce  to  cheerfulness  and  equanimity. 

It  is  the  popular  belief,  and  the  belief  of  many  ])hysicians,  that  vivid 
mental  impressions  sometimes  have  a  direct  effect  on  the  development 
of  the  foetus.  Many  cases  are  on  record  in  which  infants  Avere  born 
Avith  marks  or  deformities  corresponding  in  character  Avith  objects  which 
had  been  seen  and  had  made  a  strong  impression  on  the  maternal  mind 
at  some  period  of  gestation.  Whether  the  mind  of  the  mother  exert  a 
controlling  influence  on  the  form  and  color  of  tlie  foetus,  is  a  subject  of 
great  interest  to  the  psychologist  as  Avell  as  the  i)hysiologist  and  physi- 
cian, since  it  inA'olves  no  less  a  question  than  the  poAver  and  scope  of 
the  human  mind.  Violent  emotions,  it  is  admitted,  may  affect  directly 
most  of  the  important  organs  in  the  system.  They  may  derange  the 
liver,  causing  jaundice,  accelerate,  or  for  a  moment  suspend,  the  heart's 
action,  stimidate  the  kidneys,  causing  diuresis,  or  even  the  intestinal 
follicles,  causing  Avatery  evacuations.  But  with  all  these  organs  the 
brain  is  connected  by  nerA-es  Avhicii  anatomy  reveals.  On  the  other 
hand,  the  mother  and  f(jetus  have  a  distinct  existence  as  regards  their 


MATERXAL    IMPRESSIOXS.  21 

nervous  systems,  and  even  their  blood.  Still,  the  multitude  of  facts 
Avhich  have  accumulated  justify  the  belief  that  deformity,  or  other 
abnormal  development  of  the  foetus  is,  at  times,  due  to  the  emotions  of 
the  mother.  Some  of  the  cases  related  by  Dr.  Whitehead,  in  his  Avork 
on  hereditary  diseases,  are  very  striking  and  difficult  to  explain  on  the 
ground  of  coincidence.  I  have  met  the  following  cases.  An  Irish 
Avoman  of  strong  emotions  and  superstitions  was  passing  along  a  street 
in  the  first  montlis  of  her  gestation,  when  she  Avas  accosted  by  a  beggar, 
Avho  raised  her  hand,  destitute  of  thumb  and  fingers,  and  in  "  God's 
name "'  asked  for  alms.  The  woman  passed  on  ;  but  reflecting  in  Avhose 
name  money  was  asked,  felt  that  she  had  committed  a  great  sin  in  re-' 
fusing  assistance.  She  returned  to  the  place  Avhere  she  had  met  the 
beo-gjar,  and  on  different  days,  but  never  afterward  saw  her.  Harassed 
by  the  thouglit  of  her  imaginary  sin,  so  that  for  weeks,  according  to 
her  statement,  she  Avas  made  Avretched  by  it,  she  approached  her  con- 
finement. A  female  infant  Avas  born,  otherwise  perfect,  but  lacking  the 
fingers  and  thumb  of  one  hand.  "The  deformed  limb  Avas  on  the  same 
side,  and  it  seemed  to  the  mother  to  resemble  precisely  that  of  the 
beggar.  In  another  case  Avhich  I  met,  a  very  similar  malformation  Avas 
attributed  by  the  mother  of  the  child  to  an  accident  occurring  to  a  near 
relative,  Avhich  necessitated  amputation  during  the  time  of  her  gesta- 
tion. I  examined  both  of  these  children  Avitli  defective  limbs,  and  have 
no  doubt  of  the  truthfulness  of  the  parents.  In  May,  18G8,  I  removed 
a  supernumerary  thumb  from  an  infant,  Avhose  mother,  a  baker's  Avife, 
gave  me  the  folloAving  history  :  Xo  one  of  the  fiimily,  and  no  ancestor, 
to  her  knoAvledgo,  presented  this  deformity.  In  the  early  montlis  of 
her  gestation  she  sold  bread  from  the  counter,  and  nearly  every  day  a 
child  Avith  double  tluunb  came  in  for  a  penny  roll,  presenting  the  penny 
between  the  thumb  and  the  finger.  After  the  third  month  she  left  the 
bakery,  but  the  malformation  Avas  so  impressed  upon  her  mind  that  she 
Avas  not  surprised  to  see  it  reproduced  in  her  infant. 

Professor  William  A.  Hammond,  of  this  city,  in  an  interesting  paper 
on  the  "Influence  of  the  Maternal  INIind,"  etc.  (Quartcrlt/  Jounial  of 
I\i/cholo[/ical  Medicine^  January,  1SG8),  says  :  "  The  chances  of  these 
instances,  and  others  Avhich  I  have  mentioned,  being  due  to  coincidence, 
are  infinitesimally  small,  and  though  I  am  careful  not  to  reason  upon 
the  principle  of  I'OST  HOC,  ERGO  propter  hoc,  I  cannot,  nor  do  I  think 
any  other  person  can,  no  matter  hoAV  logical  may  be  his  mind,  reason 
fairly  against  the  connection  of  cause  and  effect  in  such  cases.  The 
correctness  of  the  facts  can  only  be  questioned ;  if  these  be  accepted, 
the  probabilities  are  thousands  of  millions  to  one  that  the  relation 
between  the  phenomena  is  direct."  Professor  Dalton  also  says  {Human 
Plii/Hiologii):  "There  is  now  little  room  for  doubt  that  various  defor- 
mities and  deficiencies  of  the  fiDCtus,  conformably  to  the  popular  belief, 
do  really  originate  in  certain  cases  from  nervous  impressions,  such  as 
disgust,  fear,  or  anger,  experienced  by  the  mother."  The  ol)servations 
on  Avhich  this  belief  is  based  relate  Ijoth  to  man  and  the  lower  animals. 
A  very  strong  argument  in  its  support  is,  as  Professor  Hammond 
remarks,  the  ])opular  opinion,  Avhich  dates  back  to  the  time  of  Jacob. 
(Genesis  xxx.)     An  almost  universal  sentiment,  running  through  eentu- 


22 


CARE  OF  THE  MOTHER  IX  PREGNANCY 


ries,  is  rarely  "wholly  fallacious.     It  has  some  truth  for  its  foundation, 
especially  ■when,  as  in  this  instance,  the  subject  is  one  of  observation. 

If  maternal  emotions  affect  the  development  of  the  exterior  of  the 
foetus,  as  observations  show,  and  physiologists  admit,  the  presumption 
is  strong  that  they  may  affect  also  the  proper  development  and  adjust- 
ment of  the  parts  of  the  brain,  an  organ  so  complex  and  delicate,  and 
may  therefore  give  rise  to  idiocy.  Dr.  Seguin  (^Idiocy  and  its  Treat- 
ment, etc.,  New  York,  18GG)  thus  remarks  on  this  point :  "  Imnressions 
vv'ill,  sometimes,  reach  the  foetus  in  its  recess,  cut  off  its  leg3  or  arms, 
or  inliict  large  flesh  wounds,  before  birth,  .  .  .  from  which  we 
surmise  that  idiocy  holds  unknown  though  certain  relations  to  maternal 
impressions,  as  modifications  to  placental  nutrition." 

It  is  an  interesting  fact  that  abnormalities  of  structure,  occurring 
from  whatever  cause,  are  apt  to  be  propagated  to  descendants.  Dr. 
Carpenter  and  others  relate  instances  among  the  lower  animals,  and 
similar  instances  of  transmission  have  now  and  then  been  observed  in 
the  human  race.  Thus,  in  the  issue  of  Nature  for  March  7,  1878, 
it  is  stated  on  the  authority  of  M.  Lenglen,  a  physician  of  Arras,  that 
a  certain  M.  Gamelon  in  the  last  century  had  two  thumbs  on  each  hand, 
anil  two  great  toes  on  each  foot ;  this  peculiarity  did  not  appear  in  the 
son,  but  it  reappeared  in  the  three  succeeding  generations,  so  that  some 

of  the  o;reat-2;reat-o;randchildren 
Fig.  1.  possessed  it  in  as  marked  a  degree 

as  their  ancestors. 

In  view  o£such  important  facts, 
the  duty  of  the  pregnant  woman 
is  rendered  the  more  imperative 
to  avoid  the  presence  of  disagree- 
able and  unsightly  objects,  as 
well  as  all  causes  of  excitement, 
and  to  remove,  as  soon  as  possible, 
vivid  and  unpleasant  impressions, 
by  quiet  diversion  of  the  mind. 

The  disastrous  results  upon  the 
foetus  of  severe  injuries  received 
by  the  mother  are  well  known  to 
the  profession,  for  premature 
labor  and  death  of  the  child,  or 
feebleness  from  its  prematurity, 
are  connnon  results  of  such  acci- 
dents. In  rare  instances  the 
child  may  be  so  injured  as  to  be 
deformed  for  life,  as  in  the  fol- 
lowing; interestin";  case :  Richard 
L.,  aged  six  years,  came,  in 
January,  1877,  to  the  children's  class  in  the  Bureau  for  the  Relief  of 
the  Out-door  Poor.  The  foUoAving  history  was  obtained:  On  November 
27,  1870,  one  month  before  the  birth  of  Richard,  the  mother  fell 
heavily  on  the  ice  when  stepping  from  a  city  car.  Uterine  hemorrhage 
resulted,  which  continued  more  or  less  freely,  producing  marked  pallor. 


MORTALITY    OF    EARLY    LIFE.  23 

till  her  confinement,  which  ocqurred  December  23d.  The  position  of 
the  child  in  utero  "svas  crosswise,  but  nothing  untoward  occurred  in  the 
delivery.  Immediately  after  its  birth,  Avhen  it  Avas  being  Avashed  by 
the  nurse,  a  blister,  about  one  inch  in  diameter,  was  observed  on  the 
rjorht  side  of  the  thorax,  located  about  one  inch  below  and  two  and  a 
half  inches  externally  to  the  nipple.  A  cicatrix  resulted  Avhich  now 
marks  the  site  of  the  sore.  When  the  blister  healed  the  child  seemed 
entirely  well,  and  nothing  more  was  thought  of  the  unusual  occurrence 
of  an  intrauterine  vesication,  till  nearly  half  a  year  had  elapsed,  when 
the  thorax  below  the  nipple  and  at  the  site  of  the  cicatrix,  was  observed 
to  be  depressed,  and  the  depression  has  continued  to  the  extent  indicated 
in  the  woodcut. 

The  ribs  at  the  point  of  depression  are  found  to  be  Avidely  separated; 
the  rib  below  being  pushed  downward  so  as  to  form  one  side  of  the  tri- 
angle, its  cartilage  the  second  side,  and  the  rib  above  the  hypothenuse. 
The  distance  of  the  perpendicular  line  passing  from  the  costo-chondral 
articulation  of  the  lower  rib  to  the  upper  rib,  or  the  hypothenuse,  is  two 
and  a  iialf  inches  by  measurement.  The  depression  in  this  triangular 
space  evidently  resulted  gradually  from  the  Avide  separation  of  the  ribs, 
and  the  consequent  loss  of  resiliency  in  the  thoracic  Avails  in  the  space 
destitute  of  bony  support.  The  child  lay  crossAvise  in  utero,  and  it 
seems  probable  that  the  injury  Avas  produced  by  the  pressure  of  its  arm 
against  the  ribs  during  tlie  fall.  Cases  like  the  above,  and  the  graver 
cases  in  Avhich  fcjetal  life  is  sacrificed,  or  the  child  is  born  to  a  puny  and 
uncertain  existence  from  prematurity,  shoAv  the  very  great  importance 
of  a  quiet  and  regular  life  on  the  part  of  one  Avho  is  about  to  become  a 
mother;  for  bodily  injuries,  like  unpleasant  sights,  occur  Avhen  least 
expected. 


CHAPTER    III. 

MORTALITY  OF  EARLY  LIFE:    ITS  CAUSES  AND  PREVENTION. 

No  fact  is  better  knoAvn  in  the  profession  than  that  the  first  years  of 
life  constitute  the  ])eriod  of  greatest  mortality. 

In  Enghmd,  Avhere  there  is  an  accurate  registration  of  births  and 
deaths,  statistics  shoAV  fifteen  deaths  in  every  hundred  infants  in  the 
first  year  of  life,  and  betAveen  four  and  five  deaths  in  the  first  month. 
Statistics  on  the  continent  correspond  with  tliose  in  England,  as  regards 
the  periods  of  greatest  mortality.  <,)iioteIet  says :  ....  "There 
die  during  the  first  month  after  birth,  lour  times  as  many  cliildrcn  ns 
during  the  secf)nd  month  after  Itirth,  and  almost  as  many  during  the 
entirety  of  the  tAvo  years  that  follow  the  first  year,  although  even  then 
the  mortality  is  high.  Tiie  tables  of  mortality  proA-e,  in  fact,  that  one- 
tenth  of  children  born  die  before  the  first  mouth  has  been  comj)leted." 


24  MORTALITY    OF    EARLY    LIFE. 

In  this  country,  in  consequence  of  deficient  registration  of  births,  the 
percentage  of  deaths  to  births  cannot  be  accurately  ascertained.  In 
this  city,  53  per  cent,  of  the  total  number  of  deaths  occur  under  the 
age  of  five  years,  and  26  per  cent,  under  the  age  of  one  year.  Accord- 
ing to  the  census  of  18G5,  there  -were  in  New  York  City  95,020 
children  under  the  age  of  five  years,  and  during  the  five  years  ending 
with  1865,  49,000  children  five  years  old  and  under  had  died.  There- 
fore, according  to  these  statistics,  more  than  one-third  of  all  the  infants 
born  in  this  city  die  under  the  age  of  five  years.  An  error,  however, 
occurs  from  the  fact  that,  while  the  death  statistics  were  complete,  it  is 
known  there  were  more  children  in  the  city  than  Avere  embraced  in  the 
census  returns.  Still  it  may,  I  think,  be  safely  stated  that  one-fourth 
of  the  children  born  in  this  city  die  before  the  age  of  five  years. 

In  less  crowded  cities  and  the  rural  districts,  it  is  knoAvn  that  the 
percentage  of  deaths  in  the  first  years  of  life  to  the  total  number  of 
deaths  is  considerably  less  than  in  New  York  City,  but  it  is  neverthe- 
•less  large. 

As  the  child  advances  toward  ])uberty,  the  liability  to  sickness  and 
death  gradually  diminishes,  but  even  the  last  years  of  childliood  present 
a  considerably  larger  percentage  of  deaths  to  the  population  than  does 
youth  or  manhood. 

The  causes  of  this  great  mortality  of  infants  and  children,  and  the 
means  of  diminishing  it,  deserve  careful  consideration. 

Some  of  the  causes  which  conspire  to  produce  it  are  to  a  considerable 
extent  unavoidable.  Such  are  congenital  vices  of  formation  of  internal 
organs.  Many  of  the  internal  malformations  necessarily  occasion  an 
early  death.  Cases  of  anencephalus,  most  cases  of  congenital  hydro- 
cephalus, of  spina  bifida,  of  cyanosis,  are  fatal  before  the  close  of 
infancy.  These  defects  of  formation  we  cannot  detect  before  birth,  and 
their  causes  are  often  obscure.  Some  of  them  seem  to  result  from 
inflammation,  believed  to  be,  occasionally,  syphilitic,  developed  at  some 
period  of  fiietal  existence.  Other  internal  malformations  are  attributable 
to  perturbating  influences,  operating  temporarily  on  the  mother  during 
gestation.  But  in  a  large  proportion  of  cases,  Ave  cannot  assign  the 
cause.  Obviously,  only  partial  success  can  attend  our  efforts,  as  regards 
prevention,  in  these  cases,  and  almost  no  success,  as  regards  the  use  of 
remedial  measures. 

Another  obvious  cause  of  the  great  mortality  of  early  life,  is  natin-al 
feebleness  of  system,  especially  in  infancy.  The  younger  the  patient, 
prior  to  the  middle  period  of  life,  the  sooner  are  the  vital  pOAvers  ex- 
hausted by  disease.  Hence  a  larger  proportion  of  infants  succumb  to 
the  same  malady,  than  children,  and  a  larger  proportion  of  children  than 
adults.  This  statement  is  true  of  infancy  and  childhood  in  general.  It 
is  a  law  in  nature,  and  cannot  be  changed  by  art.  But  there  are  many 
infants  born  Avith  hereditary  disease,  or  a  strong  predisposition  to  dis- 
ease, through  a  fault,  Avhich  is,  in  a  degree,  cui-abk',  in  the  system  of 
one  or  both  parents;  as,  for  example,  the  syphilitic,  scrofulous,  or  tuber- 
cular diathesis.  Parents  seriously  affected  by  such  diseases  cannot, 
Avithout  corrective  treatment,  have  healthy  offspring.  Their  children 
are  among  the  first  to  droop  and  die,  either  directly  from  the  inherited 


CAUSES    OF    IXFAXTILE    MORTALITY.  25 

disease,  or  from  feebleness  of  constitution  which  such  disease  entails, 
and  which  renders  them  an  easy  prey  to  other  diseases.  The  duty  of 
the  physician,  as  regards  such  parents,  is  obvious.  He  may,  by  thera- 
peutic and  hygienic  measures,  secure  a  more  healthy  progeny,  and,  so 
far  as  he  can  do  this,  he  aids  in  diminishing  the  infantile  mortality. 
He  may  sometimes,  by  timely  measures  directed  to  the  infant,  establish 
a  better  state  of  health. 

The  subject  of  hereditary  disease  is  one  of  great  interest  and  impor- 
tance, especially  as  regards  the  city  population.  Inherited  affections  are 
less  common  in  the  country,  but  in  the  city  they  contribute  largely  to 
the  number  of  deaths  in  early  life. 

Another  important  cause  of  the  great  mortality  of  children,  is  the  fact 
that  they  are  peculiarly  liable  to  certain  severe  and  fatal  maladies.  I 
allude  particularly  to  the  acute  infectious  diseases,  which,  as  a  rule, 
occur  but  once,  and  that  in  childhood.  Some  of  them,  as  scarlet  fever, 
greatly  increase  the  number  of  deaths.  They  extend  and  become 
epidemic  through  the  intercourse  of  children.  We  are  constantly  wit- 
nessing in  New  York  the  spread  of  the  acute  contagious  diseases, 
especially  of  whooping-cough,  measles,  scarlet  fever,  and  diphtheria, 
through  the  schools.  Measures  employed,  thus  far,  by  boards  of  health, 
or  other  local  authorities,  to  prevent  the  dissemination  of  these  and 
kindred  diseases,  have  been  but  partially  successful  except  in  regard  to 
smallpox.  In  the  large  public  schools  especialh%  these  maladies  are 
most  frequently  contracted,  and  from  them  they  radiate  over  the  school 
districts ;  for  if,  as  is  now  common,  at  least  in  New  York  City,  a  child 
comes  to  school  wearing  clothes  Avhich  at  home  have  lain  in  a  room 
where  a  brother  or  sister  was  sick  Avith  measles  or  scarlet  fever;  or  if 
he  enter  the  class  with  a  mild  pertussis  or  dii)hthcria,  certain  of  his 
classmates  will  probably  return  home  infected  with  the  virus  of  the 
disease.  The  same  remarks  are  applicable,  though  with  less  force,  to 
private  schools.  From  both  such  schools,  I  have  over  and  over  again 
witnessed  the  dissemination  not  only  of  the  maladies  mentioned,  but 
also  of  the  milder  infectious  diseases,  as  muin])S  and  varicella.  The 
Health  Board  of  New  York  City  have  recently,  by  sti'ingcnt  enactments 
regulating  the  schools,  accomplished  much  in  supi)ressing  this  source  of 
the  infectious  diseases. 

In  hospitals  and  asylums  for  children,  much  can  be  done  to  prevent 
the  occurrence  of  the  infectious  diseases  by  strict  surveillance  and  prompt 
isolation  of  all  suspicious  cases.  Without  such  care,  scarcely  u  year 
passes  in  which  these  institutions  are  not  scourged  by  one  or  more  of 
these  diseases.  Much  has  been  said  of  the  crowding  of  families  in  tene- 
ment-houses, so  common  in  New  York  and  other  large  cities,  by  which 
a  large  number  of  children  are  brought  under  one  roof;  of  the  unclean- 
liness  of  j)erson  and  apartment  to  which  it  leads,  and  of  the  insufficient 
air  and  space  which  it  allows  to  each.  But  one  of  the  strongest 
oltjections,  in  my  opi;iion,  to  the  present  plan  of  building  and  crowding 
tenement-houses  is  the  facility  which  it  afVords  for  the  spread  of  the  con- 
tagious diseases  of  childhood;  and  it  is  in  such  houses,  as  shown  by 
statistics,  that  these  maladies  arc  the  most  frequent  and  fatal.  The 
much-needed  enactments  or  regulations  in  relation  to  the  construction 


26  MORTALITY    OF    EARLY    LIFE. 

and  occupancy  of  such  houses,  avouM,  among  other  salutary  eifects, 
greatly  diminish  the  death-rate  from  the  infectious  maladies. 

Over  the  most  loathsome,  and  formerly  the  most  fatal,  malady  of  man- 
kind, namely,  smalliiox.  "vve  now  have,  or  can  have,  complete  control  by 
statutory  enactments  enforcing  vaccination.  It  is  only  by  carelessness 
or  the  lack  of  sufficiently  stringent  regulations  relating  to  the  matter 
that  smallpox  is  not  "stamped  out."  Again,  some  of  the  most  fatal 
inflannnatory  diseases  of  life  occur  chiefly  in  childhood,  as  croup  and 
capillary  bronchitis.  These  and  kindred  diseases  can  only  be  pre- 
vented by  proper  hygienic  management  on  the  part  of  families,  and  the 
circulation  of  tracts,  or  other  means  calculated  to  educate  families  in 
reference  to  the  management  of  children,  cannot  fail  to  diminish  the 
number  of  cases  of  such  inflammations,  and,  consequently,  of  the  deaths 
from  them. 

Another  obvious  and  important  cause  of  the  mortality  of  early  life,  is 
the  antihygienic  condition  or  state  in  ■which  many  children  live,  in  con- 
sequence ot'  the  poverty  or  gross  negligence  of  parents. 

Residence  in  insalubrious  localities,  personal  and  domiciliary  unclean- 
liness,  exposure  \vithout  proper  protection  to  vicissitudes  of  weather,  are 
fertile  causes  of  sickness  and  death.  Hence  one  reason  for  the  great  in- 
fantile mortality  among  the  city  poor,  "who  live  in  damp  and  dark  alleys, 
and  in  crowded  and  fihhy  tenementdiouses,  breathing  night  and  day  an 
atmosphere  loaded  with  noxious  gases.  All  physicians  are  aware  how 
the  most  fatal  diseases,  such  as  Asiatic  cholera,  cholera  infantum,  diph- 
theria, and  typhus  fever,  seek  the  quarters  of  the  city  poor,  and  what 
terrible  havoc  they  make  there.  All  are  aware,  also,  what  wonderful 
recoveries  result,  when  feeble  and  attenuated  infants,  gradually  sinking 
with  chronic  diseases,  induced  in  great  measure  by  the  foul  air,  are 
transferred  from  such  localities  to  the  pure  air  of  the  country. 

Careless  management  of  young  childi'en  as  regards  dress  increases 
greatly  the  liability  to  local  diseases,  such  as  commonly  occur  from  ex- 
posure to  cold.  Tliese  are  inflammatory  affections,  seated  chiefly  upon 
the  mucous  surfaces,  but  sometimes  in  parenchymatous  organs.  Adults, 
aware  of  the  effect  of  sudden  change  of  temperature  frou)  warm  to  cold, 
or  of  exposure  to  currents  of  air,  protect  themselves  by  additional  cloth- 
ing. Such  precautionary  measures  are  often  lacking  in  the  management 
of  young  children,  and  hence  one  cause  of  their  great  liability  to  local 
affections,  both  of  tlie  respiratory  and  digestive  organs. 

Ilouth,  in  his  excellent  treatise  on  Infant  Fecdirifi,  says  :  "Among 
the  most  pernicious  influences  to  young  children,  however,  we  may 
include  cold ;  the  change  of  temperature  from  45°  to  4°  or  5°  below 
zero,  as  before  stated,  producing  an  increase  of  mortality  in  London 
alone  of  three  to  five  hundred.  As  out  of  one  hundred  deaths,  how- 
ever, from  all  specified  causes,  nearly  twenty-four  occur  to  children 
under  one,  and  thirty-six  to  children  under  five,  the  great  increase  of 
mortality  to  children  by  cold  is  thus  at  once  made  obvious.  Indeed,  it 
IS  a  Iiousehold  Avord  among  us,  whicli  takes  its  origin  from  the  Registrar- 
General's  returns,  that  a  very  cold  week  always  increases  the  mortality 
of  the  very  young  and  the  very  aged." 

Lastly,  a  very  important  cause  of  mortality  in  early  life  is  the  use  of 


LOCALITIES    AXD    CLEAXLIXESS,  27 

improper  food.  In  infants,  artificial  feeding  in  place  of  the  aliment 
^vhicll  nature  has  provided  for  them,  and,  in  children,  the  use  of  in- 
nutritious  or  indigestible  articles  of  diet,  give  rise  to  diarrhoeal  mala- 
dies, emaciation,  and  death  in  numerous  instances.  Sometimes,  also, 
defective  alimentation  is  the  cause  of  scrofulous  or  tuberculous  ailments, 
and  sometimes  it  gives  rise  to  a  cachexia  or  feebleness  of  system,  "which, 
Avithout  engendering  any  positive  disease,  renders  those  thus  affected 
less  able  to  support  disease  induced  by  other  causes.  A  committee,  of 
Avhich  Professor  Austin  Flint,  Jr.,  -was  chairman,  appointed  in  18G7 
to  revise  the  "  dietary  table  of  the  Children's  Nurseries  on  Randall's 
Island,"  states,  Avith  much  truth  and  force :  "Children  .  .  .  are 
not  capable  of  resisting  bad  alimentation,  either  as  regards  quantity, 
quality,  or  variety.  At  that  age  the  demands  of  the  system  for  nourish- 
ment are  in  excess  of  the  waste ;  the  extra  quantity  being  required  for 
growth  and  development.  If  the  proper  quantity  and  variety  of  food 
be  not  provided,  full  development  cannot  take  place,  and  the  children 
grow  up,  if  they  survive,  into  puny  men  and  women,  incapable  of  the 
ordinary  amount  of  labor,  and  liable  to  diseases  of  various  kinds." 

Improper  feeding,  like  other  causes  of  mortality,  is  much  more  in- 
jurious, much  more  frequently  the  cause  of 'death,  in  the  city  than  in 
the  country.  Statistics  in  Europe,  as  well  as  this  side  of  the  Atlantic, 
establish  this  fact.  It  is  in  infancy,  and  especially  in  the  first  year, 
that  the  use  of  unwholesome  food  entails  the  most  serious  consequences. 
No  artificially  prc])are(l  food  is  a  good  substitute  for  the  mother's  milk, 
and  hence  artificial  feeding  of  the  infant,  unless  under  the  most  favor- 
able circumstances,  results  disastrously.  In  the  country,  where  salu- 
brious air  and  sunlight  conspire  to  invigorate  the  system,  where  a  robust 
constitution  is  inherited,  and  Avhere  cow's  milk,  fresh  and  of  the  best 
quality,  is  readily  obtained,  lactation  is  not  so  necessary  for  the  Avell- 
being  of  the  infant ;  but  in  the  city,  its  importance  cannot  be  too 
strongly  urged. 

The  fi)undiings  of  cities  afford  the  most  strikini;  and  convincing 
proof  of  tlie  advantages  of  lactation.  In  some  cities  foundlings  are 
wet-nursed,  Avhile  in  others  they  are  dry-nursed,  and  the  result  is 
always  greatly  in  favor  of  the  former.  Thus,  on  the  Continent,  in 
Lyons  and  Parthenay,  where  foundlings  are  Avet-nurscd  almost  from 
the  time  tliat  they  are  I'eceived,  the  deatlis  are  38.7  and  ■}•')  per  cent. 
On  the  other  hand,  in  Paris,  Ilheiras,  and  Aix,  where  the  foundlings 
Avere  Avholly  dry-nursed,  at  the  date  of  the  statistics  their  deaths  Avere 
0O.3,  G3.0,  and  80  per  cent. 

In  this  city  the  foundlings,  amounting  to  several  hundred  a  year, 
Avere  formerly  di-y-nurse<l  ;  and,  incredible  as  it  may  apj)ear,  their 
mortality  Avitli  this  mode  of  alimentation,  nearly  I'cached  100  per  cent. 
Now  Avet-nurses  are  employed  for  a  portion  of  the  foundlings,  Avitii  a 
much  more  favorable  result. 

Tiiese  facts,  to  Avliich  others  might  l)e  added  from  tlic  experience  of 
Eiirf)pean  cities,  show  the  imj)ortance  of  lactation  as  a  means  of  reducing 
infantile  mortality  in  the  cities,  ^\'llat  has  been  stated  as  regards  tho 
result  of  artificial  finding  of  f  )Mndlings,  is  true,  in  great  measure,  in 
reference  to  all  city  infants.      The  ill-effect  of  artificial  feeding  is  well 


28  WEIGHT,    GROWTH.    LACTATION. 

known  in  this  city,  and  it  is  the  common  practice  in  flimilies  to  employ 
a  hired  wet-nurse,  if,  for  any  reason,  the  motlier's  milk  is  insufficient. 

When  the  infant  has  reached  the  a^e  at  Avhich  it  is  proper  to  wean, 
the  digestive  organs  are  less  frecjuently  deranged  by  errors  of  diet. 
More  substantial  food,  and  considerable  variety  in  it,  may  now  be  not 
only  safely  allowed,  but  are  required  by  the  Avants  of  the  system. 
In  infancy,  therefore,  the  mortality  is  largely  increased  by  improper 
diet,  Avhile  in  childhood  the  diet  is  a  much  less  common  cause  of  death. 


CHAPTEE  lY. 

WEIGHT,  GROWTH,  LACTATION. 

Dr.  K.  Parker,  Resident  Physician  of  the  New  York  Infant 
Asylum,  weighed,  immediately  after  birth,  170  infonts — 89  male  and 
81  female — born  consecutively,  and  at  term,  with  the  following  result : 

Average  mule  weight 7  lbs.  11  oz. 

"        female     "       .         .         .         .         .         .         .        7    "     4    " 

Fifty  of  these,  who  were  wet-nursed,  and  apparently  well  taken  care 
of,  were  Aveighed  Avhen  one  week  old,  Avith  the  folloAving  result : 

Increase  of  weight  in  .         .         .         .         .         •         •         .32  cases. 

Loss  of  weight  in  ........     13      " 

Average  gain 4/jj  oz. 

"loss 3^V      " 

Greatest  gain         .........     12        '• 

"      loss G        " 

AVERAGE  GAIN. 

From  birth  to  age  of  4  months  (25  cases)     ...  4  lbs.  8J  oz. 

"      3  to    (j  months  (6  cases) 3    ''    3,1  " 

"      6  to    9         "  "  2    "     7i  " 

"      9  to  12         "  "  1     "  15i  " 

It  is  desirable  that  the  infant,  as  soon  as  it  requires  nutriment,  should 
receive  breast-milk.  If  it  be  fed  for  a  fcAV  days  Avith  the  bottle  or  spoon, 
it  may  be  difficult  finally  to  induce  it  to  take  the  breast;  therefore  it  is 
Avell  to  determine  early  Avhether  the  mother  Avill  be  able  to  wet-nurse 
her  infant,  so  that,  if  unable,  suitable  provision  may  be  made. 

The  matter  of  determining  beforehand  the  capability  of  the  mother 
for  Avet-nursing  has  been  investigated  by  Dr.  Donne,  of  Paris,  and  in 
his  treatise  on  Mothers  and  Infants,  he  describes  the  mode  in  Avhich  it 
may  be  ascertained.  The  desired  information,  in  his  opinion,  may  be 
ac(juired  by  examining  the  colostrum,  Avhich  is  secreted  in  small  quan- 


HIXURAXCES    TO    LACTATIOX.  29 

tity,  in  the  last  months  of  gestation,  and  which  can  he  S(^uoezed  from 
the  breast  in  sufficient  quantity  for  inspection. 

In  some  Avomen,  according  to  Dr.  Donne,  the  colostrum  is  so  scanty 
that  only  a  drop,  or  half  a  drop,  can  be  obtained  from  the  nipple  by 
careful  pressure.  This  will  be  found  by  the  microscope  to  contain  but 
few  milk-globules,  ill-formed,  ami  a  feAv  granular  bodies,  such  as  the 
colostrum  ordinarily  contains.  Such  women  almost  invariably  furnish 
poor  milk,  and  in  small  quantity.  In  other  women  the  colostrum  is 
abundant  but  thin,  resembling  gum-water;  it  lacks  the  yellow  streaks 
and  viscous  character  of  ordinary  colostrum,  and  it  flows  readily  from 
the  nipple.  The  milk  of  such  women  is  sometimes  scanty,  sometimes 
abundant,  but  it  is  watery  and  deficient  in  nutritive  principles.  In  a 
third  class  of  women  the  colostrum  is  pretty  abundant,  and  it  contains 
yellowish  streaks,  of  more  or  less  consistence,  Avhich  are  found  to  be 
rich  in  milk-globules  of  .good  size.  Women  furnishing  such  colostrum 
in  the  last  weeks  of  gestation  will  have  sufficient  milk  and  of  good 
quality.     These  latter  women  make  the  best  wet-nurses. 


Hindrances  to  Lactation  and  Physical  Conditions  Rendering  it 

Improper. 

The  priraipara  often  experiences  difficulty  in  wet-nursing  in  conse- 
quence of  a  depressed  state  of  the  nipple.  It  is  not  sufficiently  promi- 
nent to  be  readily  grasped  by  the  mouth,  and  after  ineftectual  attempts, 
the  infant  becomes  fretful  when  applied  to  the  breast,  and  perhaps  for 
a  time  refuses  it  altogether.  Multiparse  occasionally  experience  the 
same  inconvenience,  but  it  is  not  common  Avhen  there  has  once  been 
successful  lactation.  By  calmness  and  perseverance  on  the  part  of  the 
mother,  the  nursling  can  usually  be  made  to  seize  the  nipple  in  the 
course  of  a  Aveek. 

Depression  of  the  nipple  is,  to  a  certain  extent,  the  result  of  pressure 
upon  it  by  the  dress  during  gestation.  The  state  of  the  nipples  should, 
indeed,  in  those  who  have  ne\'er  suckled,  receive  early  attention,  even 
before  the  birth  of  the  infant.  Tightness  of  dress  around  the  breast, 
as  also  upon  every  part  of  the  body,  should  be  avoided,  and  from  time 
to  time  gentle  traction  should  be  made  upon  the  nipple,  if  it  be  de- 
pressed. It  may  be  draAvn  out  by  the  fingers  of  the  mother  several 
times  each  day,  or  by  a  common  breast-pump,  or  by  suction  with  a 
tobacco  pipe,  the  edge  of  the  boAvl  having  been  smoothed.  Occasionally, 
in  these  cases  of  depressed  nii)ple,  the  mother,  fatigued  and  discouraged 
by  her  frecpient  ineffectual  attempts  to  induce  the  infant  to  nui*se, 
becomes  feverish  and  excited,  so  that  the  ([uantity  of  her  milk  is  sen- 
sibly diminished.  The  physician  should  assure  her,  as  lie  usually  can 
Avith  confidence,  that  in  a  fcAV  days,  as  the  baby  becomes  a  little  stronger, 
there  Avill  be  no  difficulty  in  its  nursing.  Some  women  are  unremitting 
in  their  endeavors  to  procure  nursing.  This  should  be  forbidden,  since 
tlie  lack  of  sh'cp,  and  tbe  nervousness  Avliich  such  constant  endeavor 
produces,  tend  to  defeat  tlie  object  Avhich  they  have  in  view,  by  dimin- 
ishing the  secretion  of  milk.    .Sufficient  sleep,  freedom  from  anxiety, 


30  AVEIGHT,    GROWTH,    LACTATION, 

and  no  more  frequent  application  of  the  infant  to  the  breast  thar.  is 
required  in  successful  lactation  should  he  enjoined.  Occasionally  Ave 
can  best  succeed  in  procuring  lactation  under  these  circumstances  of 
discouragement  by  the  aid  of  another  infant,  older,  more  vigorous,  and 
better  able  to  seize  the  nipple.  An  exchange  of  infants  for  a  few  times 
may  remedy  the  difficulty. 

Occasionally  suckling  is  rendered  difficult  and  painful  by  too  long 
delay  before  applying  the  infant  to  the  breast.  When  the  mother  has 
rested  a  few  hours  after  her  confinement,  about  six  in  ordinary  cases, 
lactation  may  commence.  There  is,  at  first,  but  very  little  milk,  often 
only  a  few  drops,  but  the  secretion  is  promoted  by  nursing,  so  that  the 
requisite  amount  is  sooner  obtained  than  when  the  infant  is  kept  from 
the  breast  till  the  second  or  third  day.  If,  as  some  j.iiysicians  advise, 
suckling  be  deferred  till  the  breasts  are  full  and  tender,  and  if,  as  is 
often  the  case  with  primipar;v,  the  nipples  arc  also  tender,  many  mothers 
lack  the  fortitude  required  to  allow  their  infants  to  obtain  a  sufficient 
amount  of  milk.  Excoriated  and  fissured  nipples  constitute  a  serious 
impediment  to  lactation.  They  are  very  sensitive  on  pressure,  and  are 
long  in  healing.  They  are  fully  described  in  works  which  relate  to 
female  diseases,  and  their  treatment  pointed  out.  Occasionally  fissured 
nip}iles  do  harm  to  the  infant  by  the  blood  which  escapes  and  is  swal- 
lowed with  the  milk.  A  case  is  related  in  which  positive  indigestion 
was  caused  in  this  way;  the  infant  vomiting,  after  each  nursing,  milk 
mixed  with  blood.  The  local  hindrances  to  lactation  described  above 
can,  in  most  instances,  be  relieved  in  the  course  of  a  few  weeks.  To 
what  extent  menstruation  and  pregnancy  are  detrimental  to  the  nursing, 
and,  therefore,  contraindicate  lactation,  will  be  considered  in  another 
section. 

There  is,  occasionally,  a  constitutional  state  of  the  mother  which 
necessitates  either  the  employment  of  a  hired  wet-nurse  or  Aveaning. 
This  is  the  case  Avhen  there  is  a  strong  tendency  to  tuberculosis.  If 
the  complexion  be  pallid,  the  system  at  all  emaciated,  and  suckling  be 
attended  by  more  or  less  exhaustion,  and  if  with  fair  trial  of  wine  and 
tonics  no  improvement  folloAv,  the  physician  is  justified  in  forbidding 
further  attempts  at  w'et-nursing.  If,  under  such  circumstances,  an 
hereditary  tendency  to  tu])erculosis  exist,  it  is  his  duty  positively  to  in- 
terdict nursing.  The  opinion  of  the  physician,  in  such  a  matter,  should 
be  formed  after  mature  deliberation.  There  are  many  women  who, 
suffering  temporarily  from  illness,  and  discouraged,  are  ready  at  once 
to  abandon  their  infants  to  the  care  of  others,  with  the  least  encourage- 
ment on  the  part  of  the  physician  to  do  so,  but  who,  by  attention  to 
their  own  health,  and  especially  by  taking  more  sleep,  soon  recover 
from  their  depression,  and  become  good  wet-nurses.  On  the  other 
hand,  night-sweats,  a  cough,  and  progressive  decline  in  health,  show 
the  need  of  immediate  suspension  of  wet-nursing. 

Sometimes  women,  prior  to  pregnancy,  present  indid^itable  evidence 
of  tuberculosis,  but  l)y  the  improved  general  health  which  attends  preg- 
nancy, the  disease  is  temporarily  arrested.  Such  women  should  never 
■ruckle  their  infants.  If  they  do,  they  soon  lose  all  that  was  gained, 
and  the  disease  advances  rapidly.     These  objections  to  wet-nursing  in 


HIXDRAXCES    TO    LACTATIOX.  3l 

such  a  state  of  health  apply  to  the  mother.  There  are  also  objections 
as  reizards  the  infant.  The  milk  of  those  in  decidedly  infirm  health 
is  deficient  in  nutritive  principles.  Their  infants,  therefore,  are  ill- 
nourished,  and,  if  they  have  inherited  a  predisposition  to  tuberculosis, 
there  is  great  danger  that  this  disease  Avill  be  developed  in  them ; 
whereas,  with  healthy  wet-nursing,  even  a  strong  predisposition  may 
remain  latent.  M.  Donne  relates  the  following  instructive  cases,  Avhich 
show  the  danger  which  sometimes  attends  suckling,  and  the  imperative 
necessity  which  may  arise  of  discontinuing  it.  "A  very  light-com- 
plexioned  young  mother,  in  very  good  health,  and  of  a  good  constitu- 
tion, though  somewhat  delicate,  was  nursing  for  the  third  time,  and,  as 
regarded  the  child,  successfully.  All  at  once  this  young  woman  expe- 
rienced a  feeling  of  exhaustion.  Her  skin  became  constantly  hot;  there 
were  cough,  oppression,  night-sweats;  her  strength  visibly  declined,  and 
in  less  than  a  fortnight  she  presented  the  ordinary  symptoms  of  con- 
sumption. The  nursing  was  immediately  abandoned,  and  from  the 
moment  the  secretion  of  milk  had  ceased,  all  the  troubles  disappeared." 
"  A  woman  of  forty  years  of  age  .  .  .  having  lost,  one  after  another, 
several  children,  all  of  whom  she  had  put  out  to  nurse,  determined  to 
nurse  the  last  one  herself.  .  .  .  This  woman,  being  vigorous  and 
well  built,  Avas  eager  for  the  work,  and,  filled  with  devotion  and  spirit, 
she  gave  herself  up  to  the  nursing  of  her  child  with  a  sort  of  fury.  At 
nine  months  she  still  nursed  him  from  fifteen  to  twenty  times  a  day. 
Having  become  extremely  emaciated,  she  fell  all  at  once  into  a  state  of 
weakness,  from  Avliich  nothing  could  raise  her,  and  two  days  after  the 
poor  woman  died  of  exhaustion." 

A  very  similar  case  recently  occurred  in  my  practice.  A  youns^ 
and  healthy  Avoman  from  the  country,  suckling  her  second  infant,  on 
coming  to  the  city  lived  in  a  dark  and  very  imperfectly  ventilated 
room  on  the  first  floor,  and  in  the  rear  of  a  croAvded  tenement-house. 
She  soon  lost  her  appetite,  but  continued  suckling  for  three  months, 
when  she  became  so  anremic  and  feeble  that  she  Avas  compelled  to  seek 
medical  advice.  She  died  without  local  disease,  notAvithstanding  the 
most  nutritious  diet  and  free  use  of  stimulants  and  tonics. 

Constitutional  syphilis  in  the  mother  does  not  contraindicate  lacta- 
tion. It  is  probable  that  the  infant  also  has  it.  The  mother  should 
take  anti-syphilitic  remedies,  Avhich  Avill  eradicate  the  disease  in  herself, 
antl  also,  if  it  be  present,  in  the  infant.  Febrile  affections,  also,  do  not 
in  general  contraindicate  lactation.  They  may,  hoAvever,  for  a  time, 
diminish  the  quantity  of  milk  or  impair  its  quality.  If,  hoAvever,  the 
mother  be  in  a  critical  state,  or  much  reduced,  Avhatever  the  disease, 
suckling  sliould  cease.  Whether  or  not  the  infant  should  be  taken 
from  the  brciist,  if  the  mother  be  suflering  from  one  of  the  essential 
fevers,  depends  on  the  severity  of  the  malady,  and  the  degree  of  her 
exiiaustion.  Twice  I  have  known  newly  born  infants  to  be  suckled  by 
mothers,  Avhile  the  latter  had  scarlet  fever,  Avithout  contracting  it,  but 
suffering  immediately  afterAvard  from  protracted  and  severe  eczema.  In 
the  country,  Avhere  artificially  fed  infants,  as  a  rule,  do  Avell,  it  might  be 
best  to  Avean  if  the  mother  be  affected  with  such  a  disease,  but  in  the 
city  eczema  is  less  dangerous  than  the  diarrhccal  affections  Avhich  early 


S2  -WEIGHT,    GROWTH,    LATATIOX. 

■weaning  is  apt  to  entail.  In  most  cases  of  typhus  and  typhoid  fevers, 
Aveaning  or  procuring  a  Avet-nurse  is  necessary,  on  account  of  the  de- 
pression of  the  vital  powers  "which  these  diserses  produce. 

Inflammatory  afl'cctions,  unless  of  a  dangerous  character,  do  not  ordi- 
narily interfere  'with  lactation,  except  that  the  quantity  of  milk  in 
somewhat  diminished.  In  severe  inflammation,  it  may  be  so  necessary 
to  husband  the  strength,  or  to  keep  the  patient  perfectly  quiet,  that 
suckling  her  inftint  -would  be  injudicious.  It  should  then  be  transferred 
to  a  Avet-nurse  or  •weaned.  Inflammation  of  the  breast  often  presents 
an  impediment  to  lactation.  It  is  a  common  and  painful  afl'ection, 
suspending  or  greatly  diminishing  the  secretion  of  milk  in  the  affected 
gland.  Nursing  should  cease  as  soon  as  there  are  evident  signs  of  in- 
flannnation,  unless  it  be  limited  to  a  small  part  of  the  gland.  General 
heat  of  the  breast,  Avith  tenderness  and  induration  extending,  over  a 
consideralde  part  of  it,  indicates  the  need  of  the  immediate  removal  of 
the  infant  from  it.  Lactation  must  be  restricted  to  the  unaffected  side. 
It  is  often  the  case  that  the  volume  of  the  inflamed  gland  is  consider- 
ably increased  from  the  afflux  of  blood  to  it,  and  from  the  interstitial 
exudation,  Avhile  it  contains  little  or  no  milk,  and  attempts  at  lactation, 
under  such  circumstances,  are  injurious  to  the  mother  as  Avell  as  to  the 
infant.  The  cause  of  the  swelling  should  be  explained  to  the  mother, 
Avho  commonly  attributes  it  to  the  accumulation  of  milk,  and  Avorries 
herself  and  the  infant  by  attempts  to  make  it  nurse.  As  the  inilam- 
mation  abates,  by  resolution,  or  more  commonly  by  suppuration,  and 
the  normal  secretion  returns,  the  first  milk,  which  is  apt  to  be  thick 
and  stringy,  should  Ije  rejected,  after  Avhich  the  infant  may  nurse  as 
usual.  Occasionally,  the  abscess  Avhich  has  formed  in  the  breast  con- 
nects Avith  a  lactiferous  tube,  so  that  pus  may,  on  suction,  escape  from 
the  nipple.  If  this  occur,  of  course  lactation  should  be  interdicted  until 
pure  milk  is  obtained.  Pus  in  the  milk  can  sometimes  be  detected  by 
the  naked  eye.  It  presents  a  yelloAvish  or  greenish  color,  occurring  in 
streaks  Avhen  not  intimately  mixed  Avith  the  milk.  When  it  is  inti- 
mately mixed,  and  in  small  (quantity,  it  cannot  be  detected  by  the 
naked  eye,  but  the  microscope  reveals  the  ]ms-globules.  M.  Donne 
relates  a'^case  in  Avhich  he  discovered  these  globules  by  the  microscope, 
although  there  Avere  at  first  no  other  evidences  of  an  abscess,  and  doubts 
Avere  expressed  in  reference  to  the  accuracy  of  his  observation.  Finally, 
an  abscess  pointed  and  discharged. 

Sometimes,  Avhcn  the  inflammation  abates,  the  secretion  does  not 
return,  and,  Avorse  still,  occasionally  the  inflammation  has  occurred  so 
near  the  nipple  that  the  lactiferous  tubes  are  permanently  closed  by  it, 
so  that,  though  milk  form  in  the  breast,  there  is  no  escape  for  it. 
Thenceforth  lactation  must  be  entirely  from  one  breast.  . 

If  erysipelas  occur  in  the  mother,  the  infant  should  be  immediately 
taken  from  her  breast  and  from  her  arms.  If  this  disease  should  not 
be  communicated  to  the  infant  through  the  milk,  or  through  fissures  in 
Uie  nipple,  of  Avhich  there  is  danger,  still  the  milk  is  apt  to  undergo 
such  change  in  consequence  of  the  erysipelas  as  to  endanger  the  health 
of  the  child.  Thus,  one  of  the  Avet-nurses  in  the  NeAv  York  Infant 
Asylum  sickened  Avith  severe  facial  erysipelas  on  the  24th  of  April, 


COLOSTRUM.  33 

1875,  eight  days  after  the  death  of  her  baby.  She  was  wet-nursing  a 
foundling,  aged  seven  Aveeks,  at  the  time  of  the  commencement  of  the 
erysipeLas,  and  as  it  was  very  imjwrtant  that  her  milk  should  be  pre- 
served for  the  coming  hot  months,  it  was  deemed  best  to  allow  the 
nursing  to  continue,  the  infant  being  placed  in  a  crib  at  a  little  distance 
as  soon  as  it  dropped  the  nipple.  On  the  2Tth,  the  baby  was  troubled 
with  diarrhoea.  xVpril  28th,  its  morning  temperature  was  101°,  and 
that  of  the  evening  103°,  the  diarrhoea  continuing.  It  was  now  removed 
entirely  from  the  breast,  and  was  given  artificial  food.  On  the  29th 
there  was  a  decided  general  icteric  hue  of  the  infant's  surflice,  which 
continued  till  its  death  on  May  1st.  The  stools  numbered  about  eight 
daily  till  April  80th,  when  they  ceased.  The  record  which  I  preserved 
does  not  state  whether  there  was  vomiting,  but  it  had  probably  been 
slight  on  account  of  the  speedy  prostration.  Death  occurred  from  ex- 
haustion. At  the  autopsy,  from  half  an  ounce  to  one  ounce  of  pus 
was  found  in  the  peritoneal  cavity,  newly  formed  fibrin  Avas  observed 
upon  the  spleen  and  liver,  and  the  peritoneum  generally  had  lost  much 
of  its  lustre;  a  careful  microscopic  examination  of  the  liver  and  its 
ducts,  made  by  Dr.  Heitzmann,  revealed  no  anatomical  change  Avhich 
would  explain  the  icteric  hue,  and  it  seemed  probable  that  this  was  due 
to  the  altered  state  of  the  blood.  The  mucous  membrane  of  the  intes- 
tines exhibited  vascular  streaks,  and  its  follicles  Avere  distinct.  The 
lesions,  therefore,  indicated  intestinal  catarrh.  Nothing  unusual  Avas 
observed  in  the  heart  and  lungs  of  the  infant.  Its  life  had  apparently 
been  sacrificed  by  the  unhealthy  nursing. 


Colostrum. 

The  milk  secreted  during  gestation,  and  immediately  after  the  birth 
of  tbe  infant,  differs  in  its  gross  appearance,  as  Avell  as  chemical  and 
microscopical  characters,  from  that  which  is  ordinarily  secreted  during 
lactation.  It  is  termed  Colostrum.  It  has  a  turbid  and  yelloAvish 
appearance,  and  is  somewhat  viscid.  It  is  decidedly  alkaline,  and 
undergoes  luetic  acid  fermentation  more  readily  than  common  milk,  and 
it  also  contains  more  solid  matter.  It  has  an  excess  of  fat,  of  salts, 
and,  according  to  Simon,  also  of  sugar.  It  appears,  from  Simon's 
analysis,  that  the  solid  matter  of  colostrum  is  about  17  per  cent.,  while 
that  of  the  ordinary  breast-milk  is  about  11  per  cent. 

Examined  by  the  microscope,  the  colostrum  is  seen  to  contain  oil- 
globules  and  a  viscid  substance,  Avhich  often  assumes  an  OA'oid  or  globular 
form,  but  which  also  exists  in  irregidar  masses  of  considerable  size. 
This  substance  has  been  thought  by  some  to  be  mucus,  but  it  is  dis- 
solved by  iicctic  acid  and  jjotash,  and  is  tinged  yelloAV  by  a  Avatcry 
solution  of  iodide.  It  is  therefore  to  be  regarded  as  albuminous.  Em- 
bedded in  this  substance  are  oil-globules,  Avhich  arc  for  the  most  part  of 
small  size,  Avhile  the  free  oil-globules  of  colostrum  are  larger  than  those 
occurring  in  healthy  milk.  This  viscid  substance,  with  the  imjirisoned 
oil-globules,  constitutes  what  has  been  designated  the  ''colostrum-cor- 
puscles."   Some  have  erroneously  considered  the  "  colostrum-coi'jiuscles  " 

8 


34 


"WEIGHT,    GROWTH,    LACTATION, 


to  be  compound  o-ranular  cells.  The  compound  granular  cell,  or  cor- 
puscle, is  a  cell  Avliicli  lias  undergone  fatty  degeneration.  It  is  distended 
Avitli  oil-globules  to  i)crlia])S  twice  or  thrice  its  normal  size.  On  the 
other  hand,  examination  of  the  "colostrum-corpuscles"  fails  to  detect 
a  cell-wall,  and  the  large  and  irregular  size  of  some  of  these  corpuscles 
negatives  the  idea  that  they  are  cells.  The  oil-globules  contained  in 
the  viscid  substance  are  more  readily  acted  on  by  ether  than  are  the 
free  oil-globules. 

The  colostrum  is  replaced  by  milk  of  the  normal  character  in  six  to 
eight  days ;  sometimes  as  early  as  the  third  or  fourth  day  after  delivery. 

Fig.  2. 


Milk-Klubules. 


Colostrum-corpuscles. 


In  exceptional  instances  the  colostrum  does  not  disappear  for  several 
Aveeks,  and  it  may  reappear  at  any  time  during  lactation,  as  a  conse- 
quence of  derangement  of  the  system,  or  from  disease.  It  is  assimilated 
with  difficulty  by  the  digestive  organs  of  the  infant,  producing  usually 
a  laxative  effect.  It,  therefore,  aids  in  the  removal  of  the  meconium, 
and,  being  a  normal  secretion  in  the  first  -week  of  lactation,  it  is  to  be 
regarded  as  beneficial.  Continuing  longer  than  the  first  week,  its  effect 
is  deleterious.  It  produces  evident  dci'angement  of  the  digestive  organs, 
and  the  infant  that  haliitually  nurses  it  never  thrives.  It  has  diarrhoea 
or  vomiting,  becomes  more  or  less  emaciated,  and  suffers  from  colicky 
pains.  Sometimes  an  extreme  degree  of  exhaustion  is  reached  before 
the  cause  is  suspected,  for,  if  the  milk  be  pretty  abundant,  the  admix- 
ture of  colostrum  with  it  cannot  be  detected  by  the  naked  eye.  The 
microscope  alone  reveals  it.  The  following  is  an  interesting  example 
of  this  fact.  In  186H,  an  infant  six  weeks  old  Avas  brought  to  me, 
with  the  following  history :  The  mother  had  for  several  years  been 
troubled  with  dyspeptic  symptoms,  but  had  otherAvise  been  in  good 
health.  The  infant  at  birth  was  fleshy  and  strong,  but  after  the  first 
Aveek  it  had  never  tlirived  like  other  infants.  It  nursed  regularly,  and 
the  quantity  of  milk  Avas  apparently  sufficient,  but  it  vomited  as  soon 
as  it  ceased  nursing;  it  Avas  much  emaciated,  and  tlie  bowels  Avere 
habitually  constipated.  The  digestive  organs  of  the  infant  had  been  in 
this  unhealthy  state,  Avith  little  A^ariation,  from  the  first  week,  and  it 
AA-as  very  evident,  from  the  emaciation  and  exhaustion,  that  it  must  soon 
perish  unless  some  change  Avere  effected.  The  milk  of  the  mother 
presented  the  usual  appearance  to  the  naked  eye,  but  under  the  micro- 
scope colostrum-corpuscles  Averc  observed.     A  Avet-nurse  Avas  immediately 


HUMAN    MILK. 


35 


obtained,  and  from  that  moment  the  gastrointestinal  symptoms  disap- 
peared, with  a  rapid  recovery.  This  case  shows  at  once  the  evil  effects 
of  the  colostrum,  and  the  need  of  a  microscopic  examination  of  the  milk 
whenever  the  nurslinjr  suffers  from  lactation. 


Human  Milk. 

The  specific  gravity  of  human  milk  is  about  1032.  It  has  been  care- 
fully analyzed  by  different  chemists,  with  nearly  the  same  result.  The 
following  table,  prepared  by  M^l.  Yernois  and  Becquerel,  gives  the  pro- 
portion of  the  various  ingredients  in  1000  parts: 

Water 889.08 

Suijai- 43.64 

CHsein  and  extractive   ........  39.24 

Butter 26  66 

Salts  (ash)     .        .      ' 1.38 


1000.00 


Recently  Prof.  Albert  R.  Leeds  has  analyzed  forty-three  samples  of 
healthy  human  milk,  Avith  the  following  results  : 


Average. 

Minimum. 

Maximum 

Specific  gravity     . 

.         1  0317 

1.030 

1.0353 

Water  .... 

.     86.766 

83,34 

89.09 

Total  solids  . 

.     13.234 

10.91 

16.66 

Total  solids  not  fat 

.       9  221 

6.57 

12.09 

Fat        ...         . 

.       4.013 

2.11 

6  89 

Milk-siicjar    . 

.       6.097 

5.40 

7.02 

Albuminoids 

.       2.058 

0.85 

4.86 

Ash        .... 

.       0.21 

0  13 

0.35 

It  is  seen  that  the  constituents  of  healthy  human  milk  vary  consid- 
erably in  different  women,  especially  the  albuminoids,  which  are  the 
nutritive  part.  Leeds  found  all  the  samples  alkaline  except  one,  which 
was  neutral.  The  heat-producing  constituents,  the  carbohydrates,  fat, 
and  suirar  varv  less  than  the  albuminoids.  Althouo-h  human  milk 
seems  thinner  than  cow's  milk,  it  nevertheless  contains  more  solids  and 
less  Avater,  and  has  a  greater  specific  gravity.  Milk  sugar  is  its  largest 
solid  constituent.  Both  the  sugar  and  the  fat  are  in  greater  proportion 
than  in  cow's  milk,  while  the  amount  of  albuminoids  is  much  less.  A 
very  important  difference  between  woman's  milk  and  cow's  milk  is  in 
the  casein,  not  only  in  the  quality,  but  quantity.  The  casein  of  cow's 
milk  coagulates  in  large,  firm  masses,  digested  with  difficulty  by  the 
infant,  and  its  quantity  i.s  nearly  five  times  greater  than  that  in  human 
milk,  as  we  see  by  the  following  anah^sis  of  Prof  Leeds.  Leeds  found 
the  average  specific  gravity  of  cow's  milk  1029, 


Woman's  Milk. 

Cow's  Milk. 

Mean.       Jlinimum. 

Maximum. 

Mean. 

Minimum. 

Maximu 

Water   . 

87.00        83.69 

90  00 

87.41 

80.32 

01.50 

Total  solids    . 

12  01           9.10 

1631 

12,50 

8.50 

10  68 

Fat 

3  00           1.71 

7.60 

3.66 

1.15 

7  00 

Milk-sugar    . 

6.04           4.11 

7.80 

4.92 

3,20 

5.67 

Casein 

0.63           0.18 

1.00 

8  01 

1.17 

7.40 

Albumen 

1.31           0  30 

2.35 

0.75 

0.21 

5  04 

Alhuuiinoids 

1.04           0,57 

4  25 

3  76 

1.38 

12,44 

Ash 

0.49           0.14 

7 

0.70 

O.TjO 

0.87 

36  WEIGHT,    GROWTH,    LACTATION. 

INIilk.  henvx  the  sole  food  of  early  inflmcy,  contains  all  the  nutritive 
principles  Avhich  are  required  for  the  growth  and  repair  of  the  different 
tissues.  Most  of  the  salts  which  occur  in  the  tissues  exist  primarily 
in  the  milk.  Phosphate  of  lime,  phosphate  of  magnesium,  phosphate 
of  the  peroxide  of  iron,  chloride  of  potassium,  and  chloride  of  sodium, 
known  to  exist  in  cow's  milk,  are  believed  to  occur  also  in  human  milk. 
Epithelial  cells  are  .sometimes  present,  derived  from  the  lining  mem- 
brane of  the  lactiferous  tubes. 


Modification  of  Milk  in  Consequence  of  the  Diet. 

The  relative  proportion  of  the  different  ingredients  of  the  milk  varies 
according  to  the  diet.  If  the  diet  be  poor,  the  amount  of  water  increases, 
and  that  of  butter  and  casein  diminishes.  Lehmann  says  (Phj/s.  C/iem- 
istry,  vol.  ii.  p.  Go) :  "  From  experiments  made  on  bitches,  it  would 
appear  that  a  vegetalile  diet  renders  the  milk  riclier  in  butter  and 
sugar ;  while  the  solid  constituents  are  augmented  when  a  sufficient 
quantity  of  mixed  food  is  given.  Peligot  found  the  milk  of  an  ass  most 
rich  in  casein  Avhcn  the  animal  had  been  fed  on  beet-root ;  while  it  was 
richest  in  butter  when  the  food  had  consisted  of  oats  and  lucerne.  Fat 
food  increases  the  quantity  of  the  butter.  Boussingault  found  the  milk 
of  a  coAv  richer  in  casein  Avhen  the  animal  had  been  fed  on  potatoes  than 
when  other  food  was  taken.  Reiset  found  that  the  milk  of  cows  which 
were  at  grass  was  much  richer  in  butter  than  when  the  animals  had 
stood  all  night  in  their  stall  without  food ;  but  Playfair  found,  on  the 
contrary,  that  the  quantity  of  butter  in  the  milk  increased  during  the 
night  as  much  as  during  their  stall-feeding,  but  that  the  quantity  of 
butter  in  the  milk  was  considerably  diminished  by  the  motion  of  the 
animals  in  the  fiehls."  ^  Simon  made  the  following  analyses  of  the  milk 
of  a  poor  woman.  She  was  suddenly,  during  the  period  of  lactation, 
deprived  of  the  means  of  support,  so  that  her  food  was  insufficient  in 
quantity,  and  of  poor  quality.  The  amount  of  her  milk  was  not  dimin- 
ished by  privation,  but  the  solid  constituents  were  reduced  to  86  parts 
in  1000.  After  this,  for  a  time,  her  diet  was  nutritious  and  abundant, 
the  quantity  of  milk  was  increased,  and  the  solid  constituents  amounted 
to  119  parts  in  1000.  Her  diet  was  again  reduced,  with  a  reduction 
of  the  solid  elements  to  98  in  1000,  and,  at  a  later  period,  the  diet  was 
again  nutritious,  with  an  increase  of  the  solid  elements  to  126.  The 
chief  variation  observed  in  the  milk  of  this  woman  was  in  the  amount 
of  butter. 


Modification  of  Milk  from  its  Retention  in  the  Breast. 

M.  Peligot  has  clearly  demonstrated  that  the  longer  milk  is  retained 
in  the  breast  the  more  watery  it  becomes.  This  is  explained  on  the 
supposition  that  the  solid  portion  is  first  absorbed.  Therefore,  the 
milk  is  richer  the  more  frequently  it  is  removed  from  the  breast,     A 

'  Animal  Chem.,  S3-(ionham  Soc.'s  Tran.,  vol.  ii.  p.  55. 


MODIFICATIOX    OF    MILK    BY    AGE.  37 

similar  fact,  which  has  the  same  exphmation,  has  hjng  been  known, 
namely,  that  the  first  milk  taken  from  the  breast  is  thinnest,  Avhile  that 
Avhich  flows  last  is  richest.  That  first  removed  has  remained  longest  in 
the  gland,  while  that  which  comes  last  is  but  reccntl\^  secreted. 

A  knowledge  of  this  fact  is  of  considerable  practical  importance. 
The  milk,  as  M.  Donne  has  shown,  may  be  too  rich,  so  as  to  cause  in- 
digestion, with  more  or  less  enteralgia,  in  the  infant.  Some  nurslings, 
if  the  milk  be  too  rich  and  abundant,  reject  a  part  of  it  by  vomiting, 
but  others  do  not,  and  suffer  the  consequence  in  derangement  of  the 
digestive  organs.  For  such  cases  the  remedy  is,  to  give  the  breast  less 
frequently,  by  Avhich  a  less  amount  of  milk  is  taken,  and  milk  of  a 
poorer  quality.  On  the  other  hand,  if  there  be  poverty  of  the  milk, 
and  the  infant  be  insufficiently  nourished,  the  mi;k  is  more  nutritious, 
if  the  nursing  be  at  short  intervals. 


Modification  of  Milk  by  Age  and  by  Mental  Impressions. 

The  composition  of  milk  varies,  also,  according  to  the  age  of  the 
infant.  Simon  analyzed  the  milk  of  a  woman'at  intervals  for  the  period 
of  about  six  months.  In  this  case  the  amount  of  casein  at  first  was 
small,  but  the  quantity  increased  during  the  two  months  succeeding  de- 
livery, after  which  it  was  nearly  stationary.  A  similar  increase  was 
observed  in  reference  to  the  saline  substances.  The  sugar,  on  tlie  other 
hand,  diminished  in  ({uantity  as  the  infant  grew  older,  its.  maximum 
amount  being  in  the  first  and  second  months.  The  quantity  of  butter 
in  the  milk  varies  from  day  to  day  more  than  the  other  elements. 

Many  observations  have  been  published  which  show  that  the  composi- 
tion of  the  milk  may  be  materially  changed  by  mental  impressions.  The 
infant  has  died  suddenly  in  the  act  of  nursing,  after  his  mother  had  been 
violently  excited.  Such  a  case  is  related  by  Tourtnal.  The  infant 
ceased  nursing,  gasped,  and  died  in  the  mother's  lap.  In  other  cases 
convulsions  have  occurred.  MM.  Becquerel  and  Vernois  made  the  chemi- 
cal analysis  of  the  milk  of  a  woman  in  a  state  of  nervous  excitement,  and 
found  that  the  solid  constituents  were  diminished  to  ',•!  ])arts  in  1000, 
the  most  marked  diminution  being  in  the  butter,  which  was  only  about 
5  parts.  In  a  case  related  by  Parmentier  and  Deyeux  the  milk  became 
watery  and  viscid,  and  remained  so  till  the  nervous  attacks,  from  which 
the  patient  suffered,  had  ceased.  Dairymen  are  well  aware  how  ill- 
treatment  and  the  separation  of  the  calf  from  the  cow  diminish  the 
milk  which  she  yields.  A  new  milkman  seldom  obtains  as  nnu-h  milk 
as  one  with  whom  the  cow  is  familiar.  Bouchut,  alluding  to  the  influ- 
ence of  the  moral  affections  on  the  secretion  of  milk,  makes  the  follow- 
ing remark,  the  truth  of  which  most  mothers  will  acknowledge:  "It  is 
also  a  fact,  that  the  sight  of  the  nursling,  the  idea  of  seeing  it  at  the 
breast,  and  the  joy  which  certain  mothers  thence  experience,  exercise  a 
moral  influence  over  the  secretion  of  the  milk  entirely  independent  of 
their  will.  They  feel  the  draught  of  milk  as  soon  as  they  behold  their 
child,  or  think  of  it  too  deeply;  and  in  a  woman  Avho  saw  her  child  fall 
to  the  ground,  the  flow  of  milk'  ceased,  and  did  not  reappear  until  thti 
child,  having  quite  recovered,  attempted  to  take  the  breast." 


'dS  WEIGHT,    GEOWTII,    LACTATION. 


Modification  of  Milk  by  the  Catamenial  Function,  Pregnancy, 
and  Other  Causes. 

The  catamenia  reappear  in  most  women  before  the  close  of  hictation, 
often  by  the  fifth  or  sixth  month  after  delivery.  If  this  function  be  re- 
established in  the  normal  manner — that  is,  without  any  derangement  of 
the  system,  without  })ain  or  undue  profuseness — no  unfavorable  result 
ordinarily  occurs  with  the  infant.  On  the  other  hand,  if  the  mother 
sufter  any  disturbance  of  the  system,  or  if  the  menses  be  profuse,  the 
lacteal  secretion  may  be  so  changed  that  the  infant  is  injuriously  affected 
by  it.  The  symptoms  produced  are  those  of  indigestion,  such  as  abdom- 
inal pains,  more  or  less  vomiting,  and  diarrhoea.  This  result  is,  how- 
ever, in  my  experience,  quite  exceptional.  In  rare  instances,  more 
dangerous  symptoms  occur  in  the  infant.  A  case  has  been  reported  to 
me  in  which,  at  each  catamenial  period,  the  nursling  was  seized  with 
convulsions. 

Charles  Marchand  found  in  three  chemical  analyses  of  the  milk 
during  menstruation,  a  diminution  of  two  to  four  parts  in  the  butter,  of 
tAvo  to  five  parts  in  the  sugar,  and  a  diminution  in  the  casein  and 
albumen  of  two  to  five  parts.  This  seems  but  a  trilling  change  when 
we  recollect  that  human  milk  in  the  state  of  health  contains,  according 
to  the  analysis  of  M.  Kobin  and  others,  25  to  37  parts  of  butter,  37  to 
49  parts  of  sugar,  and  29  to  39  parts  of  casein,  in  1000  of  milk.  If  the 
menses  reappear  with  regularity,  when  the  infant  has  attained  the  age 
of  ten  or  twelve  months,  they  should  be  considered  as  designed  to 
supersede  the  secretion  of  milk,  which,  indeed,  usually  begins  to 
diminish.  Weaning  is  then  proper.  If  the  menses  return  early  in  the 
period  of  lactation,  and  give  rise  to  symptoms  in  the  infant  in  conse- 
quence of  the  altered  quality  of  the  milk,  it  is  best  to  allow  but  little 
nursing  during  the  catamenia,  and  to  employ  artificial  feeding  instead, 
until  the  flow  of  blood  ceases. 

The  change  produced  in  the  milk  by  pregnancy  is,  in  general,  more 
injurious  to  the  nursling  than  that  caused  by  the  reappearance  of  the 
menses.  The  milk  of  the  pregnant  woman  frequently  contains  more  or 
less  of  the  viscid  substance  which  characterizes  colostrum.  Still,  the 
milk  of  pregnancy  does  not,  ordinarily,  derange  the  digestive  function  as 
much  as  colostrum,  in  the  first  Avecks  of  lactation,  for  pregnancy  rarely 
occurs  till  after  the  infant  is  five  or  six  montlis  old,  when  the  organs 
of  digestion  are  less  readily  disturbed.  The  injurious  effect  of  preg- 
nancy on  the  infant  is  shown  by  vomiting  or  diarrhoea,  by  restlessness 
and  occasional  abdominal  pains, — in  fine,  by  symptoms  of  indigestion. 
In  many  cases,  liOAvever,  these  symptoms  do  not  occur,  and  the  infant, 
though  nursing  regularly,  continues  to  thrive.  No  doubt,  as  a  rule,  the 
nursling  should  bcAveancd  when  tliereare  clear  evi<lences  of  pregnancy, 
l)ut,  under  certain  circumstances,  Aveaning  is  injudicious.  I  have,  on 
/lifferent  occasions,  Ix'cn  called  to  infants,  in  midsummer,  dangerously 
sick  with  diarrhocal  attacks  induced  by  this  cause,  'fhese  infants  Avere, 
perhaps,  doing  Avcll,  or  suffering  but  little  from  indigestion,  Avlien  the 
mothers,  suspecting  themselves  pregnant,  at  once  AvithdrcAV  them  from 


DIFFEREXCES    IX    SUCKLIXG    WOMLX.  39 

the  breast,  and  cholera  infantum  or  a  kindred  disease  Avas  the  result. 
No  infant  in  the  city  should  be  weaned  in  the  hot  months.  It  is  much 
safer,  though  there  be  indubitable  signs  of  pregnancy,  that  it  continue 
nursing  till  the  cold  weather.  The  better  method  is,  however,  under 
such  circumstances,  to  employ  a  wet  nurse,  or  to  remove  the  infant  to 
the  country,  and  Avean  it  there.  In  cold  weather,  it  is  usually  safe  to 
Avean  an  infant  in  the  city  after  it  has  reached  the  age  of  five  or  six 
months. 

Sometimes  a  young  mother  devotes  herself  unremittingly  to  the  care 
of  her  infant,  gi\'ing  it  the  breast  every  hour  or  oftener  through  the 
day,  and  frequently  through  the  night.  She  gives  the  infant  little  rest 
and  has  but  little  herself.  This  devotion,  praiscAvorthy  as  it  is,  is 
nevertheless  very  injurious  to  both  parties  concerned.  The  rule  should 
be  repeated  and  remembered,  that  Avhile  an  infmt  may  nurse  hourly 
during  the  first  month,  .except  in  tlie  hours  Avhich  the  mother  requires 
for  sleep,  in  Avhich  it  should  not  nurse  more  than  once  or  twice,  after 
the  first  month  nursing  should  be  restricted  to  InterA^als  of  tAvo  hours 
till  the  third  or  fourth  month;  and  in  older  infints,  Avith  greater  capa- 
city of  the  stomach,  to  intervals  of  three  or  four  hours.  Too  frequent 
nursing  produces  indigestion  Avith  its  usual'  fretfulness,  and  diarrhoea, 
and  it  deprives  the  mother  of  the  mental  composure  and  rest  Avhicli  are 
required  for  successful  lactation,  but  the  more  the  infant  frets,  in  many 
instances,  the  oftener  the  mother  applies  it  to  the  breast,  AA'hich  only 
increases  the  indigestion.  Worriment  and  lack  of  sleep  tend  not  only  to 
diminish  the  mdk,  but  also  to  impair  its  quality. 

Venereal  excesses  have  a  very  injurious  effect  on  the  character  of  the 
milk.  In  our  remarks  on  the  hygienic  treatment  of  the  summer  diar- 
rhoea of  infants,  Ave  allude  to  authenticated  cases  in  Avhich  excesses  of 
this  kind  caused  fatal  intestinal  catarrh  in  the  nurslings.  Again,  the 
relative  proportion  of  the  ingredients  in  the  milk  may  habitually  vary 
from  the  normal  Avithout  any  assignable  cause,  so  as  to  bo  injurious  to 
the  infimt.  Habitual  ill-health,  as  from  plithisis,  an;\*mia,  syphilis,  or 
severe  nervous  disorder,  sometimes  so  affects  the  secretion  of  milk,  as 
to  render  it  unsuitable  for  the  infant.  It  may  cause  a  reappearance  of 
the  colostrum,  like  that  immediately  after  parturition.  Medicinal  sub- 
stances also  sometimes  occur  in  the  milk,  among  Avhich  may  be  men- 
tioned tlie  ethereal  oils,  iron,  iodide  of  potassium,  arsenic,  zinc,  mercury, 
the  salines,  bismuth,  lead,  antimony,  rendering  it  unsuitable  for  lactation. 
It  is  a  Avell-knoAvn  fact,  that  the  peculiar  flavor  of  certain  vegetables, 
taken  as  food,  may  be  noticed  in  the  milk.  It  is  admitted,  also,  that 
the  specific  virus  of  the  contagious  diseases,  at  least  certain  of  them,  may 
enter  the  milk,  so  as  to  give  I'ise  to  the  same  diseases  in  the  infant. 


Differences  in  Suckling^  "Women  as  Reg'ards  Quantity  and 
Quality  of  Milk. 

There  is  a  great  difference,  in  different  Avomen,  as  regards  the 
quantity  and  ([uality  of  their  milk,  and  even  the  mode  in  Avhich  it  is 
secreted.     The  best  Avet-nursos  are  usually  robust  Avithout  being  cor- 


-iO  WEIGHT,    GROWTH,    LACTATION. 

pulent.  Their  appetite  is  good,  and  their  breasts  arc  distended  from 
the  number  and  hvrge  size  of  the  bloodvessels  and  milk-duets.  There 
is  but  a  moderate  amount  of  fat  around  the  gland,  and  tortuous  veins 
are  observed  passing  over  it.  Sueh  nurses  do  not  experience  a  feeling 
of  exhaustion  and  do  not  suffer  from  lactation. 

The  nutriment  Avhich  they  consume  is  equally  expended  in  their  oAvn 
sustenance  and  the  supply  of  milk.  There  are  other  good  wet-nurses 
who  have  the  physical  conditions  Avhich  I  have  described,  but  whose 
breasts  are  small.  Still,  the  infant  continues  to  nurse  till  it  is  satisfied, 
and  it  thrives.  The  milk  is  of  good  quality,  and  it  appears  to  be 
secreted,  mainly,  during  the  time  of  suckling.  Other  mothers  evidently 
decline  in  health  during  the  time  of  lactation.  They  furnish  milk  of 
good  ([uality  and  in  abundance,  and  their  infants  thrive,  but  it  is  at 
their  own  expense.  They  themselves  say,  and  with  truth,  that  what 
they  eat  goes  to  milk.  They  become  thinner  and  paler,  are  perhaps 
troubled  with  palpitation,  and  are  easily  exhausted.  They  often  find 
it  necessary  to  wean  before  the  end  of  the  usual  period  of  lactation. 
There  is  another  class  whose  health  is  habitually  poor,  but  Avho  furnish 
the  usual  quantity  of  milk  without  the  exhaustion  experienced  by  the 
class  Avliich  I  have  just  described.  The  milk  of  these  women  is  of 
poor  quality.  It  is  abundant,  but  watery.  Their  inflmts  are  pallid, 
having  soft  and  flabby  fibre.  All  these  kinds  of  wet-nurses  are  met  in 
practice. 

Occasionally,  a  considerable  part  of  the  milk  is  lost  by  oozing  from 
the  breast.  This  sometimes  occurs  in  robust  women,  but  is  more  fre- 
quently associated  with  Aveakness.  It  is  then  due  to  a  relaxed  state  of 
the  orifices  of  the  milk-ducts.  Galactorrhoea,  as  the  excessive  secretion 
and  flow  of  milk  are  designated,  is  said  to  be  often  associated  with  a 
menorrhagic  diathesis :  that  is,  Avomen  Avhose  menses  have  been  profuse 
are  apt  to  have  too  abundant  a  floAV  of  milk,  corresponding  Avith  the 
menorrhagia.  It  is  said  that  galactorrhoea  is  also  apt  to  occur  in  those 
Avho  are  subject  to  discharges  from  parts  Avhich  sustain  no  immediate 
relation  to  the  breast,  as  in  cases  of  hocmorrhoidal  flux,  diabetes  insi- 
pidus, etc.  Excitement,  or  irritation  of  the  uterus  or  ovaries,  may  serve 
as  an  exciting  cause  of  galactorrhoea  in  those  predisposed  to  it,  and 
excessive  suckling  may  have  the  same  effect. 


Scantiness  of  Milk ;  its  Causes  and  Treatnaent. 

Though  the  amount  of  breast-milk  Avhich  the  infant  requires  is  less 
than  Avas  estimated  by  Gumming,  still  insufiiciency  of  this  secretion  is 
not  uncommon,  especially  in  cities.  According  to  the  statistics  of  Drs. 
Merei  and  "Whitehead,  among  healthy  mothers  there  is  insufficiency 
in  16. o  per  cent.,  Avhile  among  mothers  in  feeble  health  the  percentage 
is  46.6.  In  treating  of  this  subject  in  the  folloAving  pages,  reference  is 
'^ot  had  to  those  cases  in  which  there  is  temporary  diminution  of  milk 
from  acute  disease  or  other  perturbating  causes,  but  to  those  cases  in 
v.hich  there  is  habitual  scantiness. 

One  cause  of  scanty  secretion  of  milk  is  a  life  of  privation  or  of  daily 


SCAXTIXESS    OF    MILK.  41 

work,  Avhich  necessitates  separation  from  the  infant.  Insufficient  food 
may  render  the  milk  more  watery,  as  has  ah-eady  been  stated,  or  it  may 
cause  diminution  in  its  quantity.  The  mother  thus  situated  is  palUd. 
She  is  subject  to  palpitation  and  attacks  of  faintness.  Her  condition, 
indeed,  is  that  of  am^mia.  \Vorking  women  have  scantiness  of  milk, 
not  only  in  consequence  of  hardslii|)s,  but  also  because  they  are  usually 
separated  for  hours  from  their  inflints.  Age  is  also  a  cause  of  scanti- 
ness of  milk.  Mothers  at  the  age  of  forty  years  ordinarily  furnish  less 
milk  than  between  twenty  and  thirty.  Those  who  have  not  borne 
children  till  late  in  life,  and  whose  mammary  glands  have,  therefore, 
long  been  inactive,  have  less  milk  than  those  who  commence  bearing 
children  at  the  usual  period. 

Routh  speaks  of  hypertemia  as  a  cause  of  defective  lactation.  ''  This 
is  a  variety,"  says  he,  "which  I  have  chiefly  observed  among  hired  wet- 
nurses,  selected  from  the  poorer  classes,  and  admitted  into  wealthier 
families.  .  .  .  When  feeding  at  the  expense  of  a  master  or  mistress, 
the  amount  they  devour  often  surpasses  all  moderate  imagination.  They, 
in  fact,  gormandize.  If  in  such  instances  a  wet-nurse  be  given  all  she 
asks  for,  she  will  be  found  often  to  eat  quite  as  much  as  any  two  men 
with  large  appetites;  and,  as  a  result,  she  becomes  gross,  turgid,  often 
covered  with  blotches  or  pimples,  and  generally  too  plethoric  to  fulfil 
the  duties  of  her  position.  The  plethora,  as  first  induced,  is  of  the 
sthenic  variety,  but  it  soon  assumes  an  asthenic  character,  and,  as  the 
immediate  result,  the  breast  no  longer  secretes  its  quantum  of  milk. 
There  may  be  good  milk  secreted,  but  it  is  in  small  quantity,  and  this 
quantity  diminishes  daily.  The  breast  may  also  enlarge,  but  it  is  from 
a  deposition  of  fatty  tissue  in  and  about  it,  as  in  other  parts  of  the 
body.  The  veins  on  the  surface  become  less  apparent,  always  a  bad 
feature  in  a  suckling  breast,  till  finally  the  flow  of  milk  ceases  alto- 
gether." 

Atrophy  of  the  breast  from  the  employment  of  iodine,  or  from  long 
disuse,  is  also  a  cause  of  insufficiency  of  milk. 

It  is  so  necessary  for  the  health  and  development  of  the  infant  that 
the  milk  should  be  in  proper  (piantity  as  well  as  quality,  that  it  is  best 
in  a  work  of  this  kind  to  consider  the  treatment  of  insufficient  secre- 
tion, and,  on  the  other  hand,  of  excessive  secretion  and  loss  of  milk,  or 
galactorrhoca,  and  first  of  insufficient  or  scanty  secretion. 

The  most  efficient  mode  of  increasing  the  lacteal  secretion  is  that 
which  is  also  natural,  namely,  suction  from  the  nipple.  There  are 
many  cases  on  record  in  which  this  has  produced  the  flow  of  milk  in 
women  who  have  never  borne  children,  and  even  in  men.  liaudelocque 
mentions  the  case  of  a  girl,  eight  years  old,  who  siu^kled  her  brother 
for  a  month,  and  cases  at  the  opposite  extreme  of  life  have  been  re- 
ported; one  of  a  women  of  seventy  years,  who  wet-nursed  a  grandchild 
twenty  years  after  her  last  confinement. 

The  following  case,  which  was  un<ler  my  observation,  is  interesting 
in  this  cf.nnection  :  Lizze  S.  was  confined  witii  her  first  chihl  <»n  May 
30,  1K7G.  ^Vhen  the  baby  was  a  few  days  old,  and  before  she  had 
left  the  bed,  she  had  inflammatory  symptoms  which  proved  to  be  due 
to  pelvic  cellulitis.     Its  course  Nv as  tedious;  her  milk  diminished,  and 


42  WEIGHT,    GROWTH,    LACTATION, 

its  secretion  soon  ceased.  On  or  about  the  first  of  August  she  began 
to  sit  up,  and  on  August  11th  she  was  admitted  into  the  Sixty-first 
Street  branch  of  the  Infant  Asylum,  pale  and  wasted,  but  with  return- 
ing appetite.  She  had  no  mammary  secretion  for  eleven  weeks,  and 
her  breasts  Avere  small  and  ila1)by.  She  had  two  fistulous  openings,  one 
vaginal,  and  the  other  low  down  in  the  back,  near  the  lower  end  of  the 
sacrum  or  the  coccyx.  The  baby  was  in  a  fair  condition,  having  been 
suckled  by  other  women.  Experiences  in  this  and  other  institutions 
show  that  infants  having  breast-milk  do  far  better  and  are  much  more 
likely  to  live  than  those  without  breast-milk,  and  the  mother  was  therefore 
advised  by  one  of  the  managers — himself  a  physician — to  suckle  her 
baby,  altliough  there  was  not  a  drop  of  milk  in  her  breast,  and  nursing 
had  been  suspended  eleven  weelcs.  To  the  surprise  of  the  mother,  and 
of  the  nurses  in  the  house — to  whom  the  procedure  seemed  very  ridicu- 
lous— milk  began  to  appear  in  a  few  days.  The  mother  left  the  insti- 
tution October  8th ;  but  before  her  departure  she  was  able  to  furnish, 
perhaps,  two-thirds  the  quantity  of  milk  which  her  infant  required. 
This  case  affords  practical  illustration  of  the  fiict  that  frequent  nursing 
is  the  most  efficient  galactogogue.  Mothers  sometimes,  having  little 
breast-milk,  suckle  their  babies  at  long  intervals,  and  finally  dis- 
couraged at  the  unproductive  state  of  their  breasts  resort  to  weaning, 
when,  by  patience  and  more  frequent  lactation,  they  might  become  good 
wet-nurses.  In  the  cities,  and  during  the  sunnner  season,  in  which 
breast-milk  is  so  much  required,  the  history  of  cases  like  the  above,  and 
the  more  remarkal)le  cases  in  which  men  and  grandparents  have  had 
secretion  of  milk  and  have  suckled  infimts,  should  induce  the  physician 
to  withhold  his  consent  to  permature  weaning,  which  the  disheartened 
mother  is  apt  to  suggest,  unless  indeed  he  perceive  other  reasons  for 
weaning  apart  from  scantiness  of  milk. 

Travellers  among  barbarous  nations  or  tribes  have  often  observed 
these  cases  of  unnatural  lactation.  Humboldt  saw  a  man,  thirty-two 
years  old,  who  gave  the  breast  to  his  child  for  five  months,  and  Captain 
Franklin,  in  the  Arctic  regions,  met  a  similar  case.  Dr.  Livingstone, 
in  his  African  travels,  says  that  he  has  examined  several  cases  in  which 
a  grandchild  has  been  suckled  by  a  grandmother,  and  equally  remark- 
able instances  of  lactation  occur  among  the  negroes  of  the  Southern 
and  Middle  States.  Professor  Hall  presented  to  his  class  in  Baltimore, 
a  male  negro,  fifty-five  years  old,  who  wet-nursed  all  the  children  of  his 
mistress.  In  these  cases  of  abnormal  lactation,  so  far  as  we  have  accu- 
rate records  of  them,  it  is  ascertained  that  the  breasts  were  torpid,  and 
even  sometimes,  as  in  old  people,  atrophied  till  the  nursing  commenced. 
Titillation,  or  pressing  of  the  nipple,  caused  an  affiux  of  blood  to  the 
gland,  and  developed  its  functional  activity,  so  that  milk  was  produced 
for  the  sustenance  of  the  nursling.  Therefore,  in  case  of  scanty  secre- 
tion of  milk,  the  mother  may  increase  the  quantity  by  applying  the 
infant  often  to  the  breast.  If,  dissatisfied  with  the  small  amount  of 
nutriment  which  it  receives,  it  refuse  to  make  the  necessary  suction, 
any  other  mode  of  gentle  traction  or  pressure  may  be  em})loycd  in 
addition.  The  occasional  employment  of  another  infant,  or  a  pup, 
milking  the  breast  with  the  thumb  and  fingers,  or  the  gentle  suction  of 


SCAXTIXESS    OF    MILK.  43 

a  breast-pump,  aids  in  stimulating  the  secretion.  One  of  the  best  breast- 
pumps  kept  in  the  shops  is  that  to  Avliich  the  name  "  The  Mother's  Bless- 
ing "  has  been  applied.  Forcible  rubbing  or  traction  of  the  breast  defeats 
the  purpose  for  Avhich  it  is  employed.  It  produces  too  much  irritation 
and  tenderness.  The  best  mode  of  stimulation  is  by  nursing,  as  it  is 
the  natural  mode,  and  the  moral  effect  of  the  infant  at  the  breast  aids 
in  promoting  the  secretion. 

Another  mode  of  increasing  the  functional  activity  of  the  mammary 
glands  is  by  the  electrical  current.  The  fact  is  established  by  physio- 
logical experiments,  that  glandular  organs  can  be  made  to  secrete  more 
actively  by  the  stimulus  of  electricity,  and,  accordingly,  this  agent  has 
been  sucessfully  employed  to  promote  the  secretion  of  milk.  In  Routh's 
Infant  Feeding  several  cases  are  related  -which  show  the  beneficial  effects 
of  this  agent  (page  149  et  seq.).  Among  them  are  six  reported  by  Dr. 
Skinner,  of  Liverpool.  •  In  all  these,  one  or  two  applications  of  the 
electrical  current  sufficed  to  restore  the  secretion.  The  followinji  is 
Dr.  Skinner's  mode  of  employing  this  treatment: 

"1.  Direct. — Both  poles  must  terminate  in  cylinders,  with  sponges 
well  moistened  in  tepid  water.  The  positive  pole  is  pressed  deep  into 
the  axilla,  while  the  negative  is  lightly  apphed  to  the  nipple  and  the 
areola;  the  current  being  no  stronger  than  is  agreeable  to  the  patient's 
feelings.     The  poles  are  kept  in  this  position  for  about  two  minutes. 

"  2.  Intramammarj/. — The  poles  are  to  be,  as  it  were,  embedded  in 
the  mannna,  and  moved  about,  raising  and  depressing  both  poles  at 
once  in  and  around  the  organ  for  the  space  of  another  two  minutes. 
Tiie  same  is  to  be  done  to  both  breasts  daily,  until  the  secretion  is  pro- 
perly established.  Hitherto  one  or  two  sittings  have  always  sufficed  in 
my  hands."     {Communication  of  Dr.  Skinner  to  Dr.  Mouth.) 

In  all  cases  of  scanty  secretion  of  milk,  the  regimen  of  the  mother  is  a 
matter  of  importance.  Personal  and  domiciliary  cleanliness  is  essential 
for  successful  wet-nursing.  A  certain  amount  of  exercise  in  the  open 
air  is  conducive  to  the  health  of  the  mother,  and  to  the  secretion  of 
abundant  and  healthy  milk.  A  cjise  is  related  to  show  the  effect  of 
fresh  air  and  outdoor  exercise  on  the  lacteal  secretion.  A  lady  of 
cleanly  habits,  living  in  London,  had  a  very  scanty  supply  of  milk. 
Slie  removed  to  the  pure  air  of  the  seashore,  and  innnediatcly  the 
(piantity  ])ecame  abundant,  and  continued  so  for  months.  Such  cases 
are  not  infrequent.  A  mode  of  life  tliat  contributes  to  the  general 
healtii  of  the  mother  will  not  fail  to  augment  the  quantity  of  her  milk, 
if  it  be  scanty,  and  to  improve  its  quality. 

Much  has  l)een  written  in  reference  to  the  diet  of  women  who  suckle. 
It  is  a  popubir  belief  that  certain  articles  of  food  promote  the  secretion 
of  milk  much  more  than  other  articles,  though  equally  nutritious.  No 
doubt,  writers  have  erred  in  recommending  exclusively  this  or  that 
kind  of  food,  as  most  likely  to  produce  milk.  The  exact  kind  of  food 
which  is  preferable,  in  a  certain  case,  depends  partly  on  the  physi(iue 
of  the  individual,  and  partly  on  the  character  of  the  food  to  which  she 
has  been  accustomed.  A  mixed  diet  contributes  most  to  the  sustenance 
of  the  mother.  an<l  to  an  abundant  secretion  of  milk.  Aniiual  sub- 
stances which  furnish  a  due  supply  of  nitrogenous  aliment  should  be 


44:  SELECTIOX    OF    A    AVET-XURSE. 

given  with  the  i\irinaceous.  Mothers  palUd,  and  inclining  to  an  anoemic 
condition,  require  a  larger  proportion  of  animal  diet  than  those  in  good 
general  health.  On  the  other  hand,  plethoric  Avomen,  such  as  Routh 
describes,  Avho  with  excellent  appetite  consume  large  quantities  of  food, 
and  who  become  more  and  more  full-blooded  and  corpulent  Avhile  the 
milk  diminishes,  require  a  more  restricted  animal  diet,  in  connection 
with  more  exercise,  especially  in  the  open  air. 

There  are  certain  kinds  of  food  which  do  appear  to  have  a  galacto- 
gogue  effect  with  most  wet-nurses.  Oatmeal  gruel  is  one  of  these. 
AVet-nurses  often  remark,  after  taking  a  bowl  of  this,  that  they  feel  the 
flow  of  milk.  Cow's  milk  with  some  has  a  similar  effect.  Porter  or 
ale,  taken  once  or  twice  a  day,  also  promotes  the  secretion  of  milk, 
especially  in  those  who  have  poor  appetite,  and  whose  systems  are  some- 
what reduced. 

A  great  variety  of  medicines  has  been  used  for  their  supposed 
galactogogue  effect.  Medicines  which  improve  the  general  health  are, 
no  doubt,  sometimes  useful  for  this  purpose,  such  as  the  vegetable  and 
ferruginous  tonics  and,  perhaps,  cod-liver  oil.  But  there  are  other 
medicines  which  it  is  claimed  have  a  specific  effect  on  the  mammary 
gland,  promoting  its  secretion.  Lettuce,  winter-green,  fennel,  the 
broom  tops  (scoparius),  and  marsh-mallow,  have  been  used  for  this 
purpose.  •  There  can  be  no  doubt  that  the  aromatic  stimulants,  as 
fennel,  anise,  and  caraway  seeds,  given  in  soups,  sometimes  stimulate 
the  lacteal  secretion.  Another  medicine  which  has  been  recommended 
to  the  profession,  as  a  galactogogue,  is  castor  oil  and  the  plant  from 
which  it  is  derived. 


CHAPTER    Y. 

SELECTION  OF  A  AVET-NURSE. 

In  the  cities,  cases  are  frequent  in  which  mothers,  with  all  possible 
care  or  endeavor,  find  themselves  unable  to  suckle  their  infants.  Their 
health  is  too  poor,  or  the  milk  possesses  the  properties  of  colostrum,  or 
it  is  no  longer  secreted,  on  account  of  nervous  excitement,  or  exhaus- 
tion, or  inflammation  of  the  breasts.  The  number  of  such  cases  in  the 
city  would  surprise  physicians  who  are  familiar  only  with  the  healthy 
and  robust  mothers  of  the  country.  The  infant  thus  deprived  of  the 
mother's  milk  should,  if  practicable,  be  furnished  Avith  a  Avet-nurse. 

The  selection  of  a  wet-nurse  often  devolves  upon  the  physician,  and 
is  a  duty  of  great  responsibility.  It  is  better  to  select  one  between  the 
ages  of  twenty  and  thirty  years,  and  one  Avho  has  suckled  an  infant 
previously.      A  wet-nurse  between  the  ages  of  twenty  and  thirty  is 


EXAMIXATIOX    OF    AVET-XUE3E.  45 

usually  more  active,  cheerful,  and  conciliatory  than  one  of  a  more  ad- 
vanced age,  and  her  milk  is  more  apt  to  be  abundant  and  nutritious. 
Those  who  have  previously  suckled  and  had  charge  of  infants,  are  obvi- 
ously more  competent  to  serve  as  wet-nurse  than  are  primipar?e.  The 
milk  of  a  wet-nurse  whose  infmt  is  under  the  age  of  six  months,  will 
ordinarily  asi'ree  with  a  new-born  infant.  If  above  that  ao;e,  it  some- 
times  agrees,  but  often  does  not. 

The  most  difficult  and  responsible  task  imposed  on  the  physician  in 
the  selection  of  a  nurse,  is  to  ascertain  the  exact  condition  of  her  health, 
and  the  quantity  and  quality  of  her  milk.  Constitutional  syphilis  is 
common  in  the  class  of  women  who  present  themselves  for  wet-nursing  ; 
it  is  often  latent,  or  its  symptoms  are  easily  concealed,  and  it  is  com- 
municable by  lactation.  The  virus  may  be  received  by  the  infant  from 
fissures  or  excoriations  of  the  nip])le.  The  nursling  tainted  by  syphilis 
may,  on  the  other  hand,  .communicate  the  disease  to  the  nurse  through 
the  same  source.  It  is  not  fully  ascertained  Avhether  the  syphilitic 
virus  may  be  conveyed  to  the  infant  by  the  milk.  But  the  cases  which 
have  accumulated  in  the  records  of  medicine  are  numerous,  in  Avhich 
infants,  born  of  healthy  parents,  have  been  fully  syphilized  by  lactation 
from  diseased  nurses  (see  article  Syphilis).  These  infants  have  some- 
times led  a  short  and  miserable  existence,  and  have  occasionally  in- 
creased the  misery  of  the  household  by  imparting  the  disease  to  others. 
The  duty  is,  therefore,  imperative  on  the  part  of  the  physician  to  ex- 
amine carefully  the  wet-nurse,  in  reference  to  any  evidences  of  the 
syphilitic  taint.  Acquainted  with  the  symptoms  of  syphilis,  he  may 
usually,  by  shrewd  questioning  and  by  careful  examination  of  the  pres- 
ent appearance  and  condition  of  the  woman,  ascertain  with  considerable 
certainty  whether  her  system  has  ever  been  infected.  References  should 
also  be  obtained  and  consulted,  and,  if  practicable,  the  physician  Avho 
has  attended  her  be  communicated  with. 

It  is  safer  to  employ  a  wet-nurse,  two  months  after  her  confinement 
than  previously,  for  if  she  have  the  syphilitic  taint  it  will  by  this  time 
show  itself  in  the  innutrition,  corj'za,  and  anal  sores  of  her  infmt. 

There  are,  also,  among  the  women  who  present  themselves  for  wet- 
nursing  in  the  cities,  many  of  a  scrofulous  habit,  and  many  who  possess 
an  hereditary  tendency  to  tuberculosis,  if  indeed  they  do  not  already 
have  the  incipient  disease.  Such  applicants  sliouhl  be  rejected,  on 
account  of  the  poverty  of  their  milk  and  the  probability  that  they  will 
not  be  able  to  endure  the  debilitating  effect  of  lactation. 

The  milk  should  be  examined,  in  order  to  ascertain  its  richness  and 
quantity,  and  whether  it  contain  colostrum.  If  there  be  colostrum  after 
the  eighth  day,  it  is  probable  that  there  is  some  fault  in  the  health  or 
digestion  of  the  Avct-nurse,  and  that  her  milk  may  disagree  with  the 
infant.  It  is  not  necessary  that  the  breast  should  be  large,  in  order  to 
furnish  a  sufficient  quantity  of  milk,  since,  as  has  been  already  statc<l, 
in  some  the  secretory  function  is  active  during  the  time  of  each  nursing, 
so  that,  although  the  breasts  are  of  moderate  size,  a  sufficient  amount 
of  milk  is  iurnished.  The  nipples  should  be  well  formed  and  ])ronii- 
nent,  and  preference  is  to  be  given  to  those  wet-nurses  in  whom  bhjod- 
vcssels  are  seen  ramifying  over  the  breasts. 


46  SELECTION    OF    A    WET-NURSE. 

By  examination  of  the  milk,  its  degree  of  richness  can  be  readily 
ascertained.  A  quantity  of  it  should  be  placed  in  a  test-tube,  and  the 
cream  which  rises  to  the  top  indicates,  approximately,  the  character  of 
the  milk.  Good  milk  furnishes  tliree  per  cent  of  cream,  and  the  casein 
and  sugar  usually  correspond  in  quantity  with  the  cream.  An  instru- 
ment has  been  invented,  called  the  lactometer,  by  Avhich  the  exact 
amount  of  the  cream  can  be  ascertained.  It  is  simply  a  tube  graded 
into  100  divisions.  It  is  placed  upright  and  filled  with  milk,  and  the 
number  of  divisions  occupied  by  the  cream  indicates  its  proportion  in 
100  parts.  The  lactoscope  is  another  instrument  employed  for  the  pur- 
pose of  ascertaining  the  richness  of  the  milk.  It  consists  of  two 
concentric  tubes,  which  move  upon  each  other.  Milk  which  we  wish  to 
examine  is  poured  Avithin  the  tubes  sufficient  to  obscure  a  light  viewed 
through  it,  tliree  feet  distant.  The  column  of  milk  is  then  diminished, 
till  the  light  begins  to  be  visible.  The  size  of  the  column  indicates  the 
degree  of  opacity  and  the  richness.  The  lactoscope  was  invented  by 
M.  Donne,  and  is  described  by  him. 

Dr.  Minchin  recommends  a  simple  mode  of  determining  the  richness 
of  cow's  milk,  and  it  would  equally  answer  for  the  breast-milk.  A 
vessel  holding  about  one  ounce,  and  containing  a  gi^aduated  enamel 
slab,  passing  diagonally  from  above  downward,  is  filled  with  milk.  It 
is  then  covered  with  a  glass  slide  carried  over  it  in  such  a  way  as  to  ex- 
clude bubbles.  The  number  of  degrees  which  can  be  read,  indicates 
the  character  of  the  milk,  as  regards  its  richness. 

Examination  of  the  milk  by  the  microscope  not  only  enables  us  to 
determine  whether  there  are  abnormal  corpuscles  or  granular  elements, 
but  also  its  richness.  It  should  be  examined  before  the  cream  has 
separated.  Oil-globules  of  small  size,  and  few,  indicate  poverty  of  the 
milk ;  very  large  oil-globules  are  said  to  indicate  milk  which  is  apt 
to  be  indigestible,  especially  in  feeble  infants.  Such  are  the  free 
globules  of  the  colostrum.  Numerous  oil-globules  of  medium  size  indi- 
cate nutritious  milk.  Vogel,  in  1850,  made  the  discovery  of  vibriones 
in  human  milk.  The  fact  is  established  that  these  animalcules  may  be 
generated  in  the  milk  within  the  breast,  though  such  cases  are  not  fre- 
quent. Dr.  Gibb  descril)es  a  c:;se  w'hich  he  met.  {^Ranking  s  Abstract, 
vol.  xxxiv.)  An  infant,  seven  weeks  old,  wet-nursed  by  its  mother, 
who  had  the  appearance  of  ])erfect  health,  was,  nevertheless,  ill-nour- 
ished and  emaciated.  It  had  no  diarrhoea  or  other  apparent  disease, 
and  the  milk  was  tlierefore  examined.  A^ibriones  baculi  were  found  in 
the  milk  immediately  after  it  was  obtained  from  tlie  breast.  The  milk 
had  the  usual  amount  of  cream,  and  seemed,  to  the  naked  eye,  of  good 
quality.  According  to  Dr.  Gibb,  two  genera  of  microscopic  organisms 
occur  in  the  milk,  namely,  vibriones  and  monads.  It  is  believed  that 
the  monads  occur  in  consequence  of  fermentation  of  the  sugar  and  the 
production  of  lactic  acid.  Vogel  also  attributed  the  production  of  the 
vibriones  to  fermentation  occurring  in  consequence  of  heat  and  conge%s- 
tion  of  the  breast,  connected  with  sexual  excitement.  This  explanation 
is  probably  not  correct,  because  vibriones  sometimes  occur  when  there 
IS  no  unusual  heat  of  breast,  and  no  evidence  of  fermentation.  The  fact 
that  such  organisms  may  be  found  in  milk  which  seems  of  good  quality 


EXAMIXATIOX    OF    WET-XUESE.  47 

to  the  naked  eye,  affords   additional  proof  of  the  usefulness   of  the 
microscope  in  the  selection  of  a  wet-nurse. 

]Many  wet-nurses  have  a  return  of  the  menses  as  early  as  the  fourth  or 
fifth  month  after  delivery.  The  reestablisliment  of  this  function  in  some 
women  impairs  the  quality  of  the  milk,  so  as  to  render  it  less  nutritious, 
and  perhaps  less  digestible  during  the  time  of  the  catamenial  flow,  as 
Ave  have  stated  in  a  preceding  paragraph.  In  the  selection  of  a  wet- 
nurse,  then,  preference  should  be  given  to  one  who  does  not  have  the 
periodical  sickness;  but  if  she  be  already  employed,  and  give  satisfac- 
tion, the  reappearance  of  the  catamenia  does  not  indicate  the  need  of 
the  change  of  nurse,  unless  the  digestion  of  the  infant  be  disordered,  or 
its  nutrition  be  impaired. 

In  the  selection  of  a  wet-nurse,  attention  should  also  be  given  to  her 
mental  and  moral  traits.  Cheerfulness,  affection,  veracity,  and  a  proper 
appreciation  of  the  responsibility  of  her  situation,  enhance  greatly  the 
vakie  of  a  wet-nurse.  Not  less  important  are  habits  of  temperance  and 
cleanhness.  I  could  cite  cases  of  the  most  melancholy  results  from  the 
absence  of  these  traits.  In  one  case,  idiocy  resulted  from  an  infant  foiling 
upon  the  pavement  from  the  arms  of  a  reckless  or  intemperate  wet-nurse. 

Ill  most  cases,  the  mode  of  examination  indicated  above  suffices  to 
show  the  character  of  a  wet-nurse,  so  far  as  her  health  and  milk  are 
concerned.  It  should  be  borne  in  mind,  however,  that  the  microscope 
does  not  always  reveal  deleterious  properties  in  the  milk.  Elements 
which  are  in  a  state  of  solution,  and  are  invisible,  may  occur  in  excess, 
so  as  to  impair  the  cpiality  of  the  milk  and  render  it  indigestible.  The 
following  case,  in  which  the  saline  ingredients  seem  to  have  been  in 
excess,  is  related  by  Dr.  Hartmann  (British  and  Foreir/n  Medical 
lievievj,  vol.  xii.):  "An  infant,  whoso  mother  Avas  in  good  health  and 
had  borne  several  cliildren,  exhibited  a  lieulthy  appearance  for  the  first 
five  weeks  after  birth.  The  alvine  evacuations  then  became  copious, 
fluid,  and  discolored,  and  the  child  lost  flesh  and  strength.  After  the 
usual  remedies  had  been  vainly  administered  for  a  fortnight,  the  mother 
remarked  that  the  child  did  not  take  the  right  breast  wiUingly,  and  so 
much  did  tlie  unwillingness  increase,  that  at  length  the  mere  applica- 
tion of  the  nipple  to  the  child's  lips  occasioned  loud  crying.  On  ex- 
amination it  was  found  that  the  milk  of  the  right  breast  had  a  distinctly 
saline  taste;  whereas  the  milk  of  the  opposite  breast  was  of  the  ordinary 
sweetness ;  no  difference  of  consistence  or  color  was  discoverable.  From 
that  time  the  child  A\as  only  alloAved  to  nurse  the  left  breast,  and  in  a 
lew  days  all  diarrhoea  and  sickliness  of  appearance  vanished."  In  this 
case  there  Avas  no  appreciable  disease  of  the  breast,  although  its  secre- 
tion Avas  perverted.  The  deleterious  character  of  the  milk  Avas  dis- 
covered, not  by  any  change  in  its  appearance,  but  by  the  taste. 

It  is  obviously  very  necessary,  before  recommending  a  Avct-nurse,  to 
ascertain  Avhether  shcAvill  probably  furnish  sidficient  milk  ;  for  however 
excellent  she  may  otherwise  be,  if  she  do  not  satisfy  the  Avants  of  the 
infant  she  obviously  should  not  be  employed.  The  only  certain  Avay  of 
a.scertaining  Avhether  she  have  or  liave  not  sufficient  milk  is  by  Aveighing 
the  baby  before  and  after  the  nursing,  and  observing  Avhether  the  dif 
ference  in  the  two  Avcights  corrcsj^nds  Avith  that  given  in  the  tables  iv 
Chapter  Vll. 


48  COURSE    OF    LACTATION  —  WEANIXG. 


CHAP  TEE    YI. 

COUESE  or  LACTATION— WEANING. 

After  the  birth  of  the  inflmt,  the  mother  needs  rest  a  few  hours — 
four  or  five,  or  a  little  longer  in  tedious  and  exhaustive  cases — and  then 
it  should  be  applied  to  the  breast.  There  is  frequently  a  little  milk  at 
this  time,  and  the  act  of  nursing  promotes  the  secretion,  and  increases 
the  quantity.  The  full  secretion  is  not,  however,  established  before 
the  third  day,  and  though  the  infant  be  applied  to  the  breast  often,  it 
obtains  but  little  milk.  Infants  are  so  constituted  that  they  require 
but  little  food  until  it  is  naturally  provided  for  them,  and  the  common 
practice  of  feeding  them  to  repletion  Avith  various  sweetened  mixtures 
almost  as  soon  as  life  begins,  because  they  obtain  little  breast-milk,  is 
to  be  deprecated.  Filling  their  stomachs  in  this  Avay  has  a  tendency 
to  prevent  their  drawing  upon  the  nipples  with  the  avidity  which  is 
required  to  stimulate  a  free  ilow  of  milk.  Besides,  as  I  have  many 
times  observed,  indigestion,  diarrluca,  and  sprue,  are  common  results 
of  this  injudicious  feeding.  If,  therefore,  the  infant  be  applied  to  the 
breast  every  second  hour  when  the  mother  is  awake  till  the  third  day, 
and  be  fed  nothing  besides,  there  need  be  no  anxiety  as  regards  its 
nutrition.  If  on  the  third  day  the  breasts  do  not  begin  to  fill,  and  the 
secretion  be  delayed,  a  little  fresh  cow's  milk,  diluted  with  double  its 
quantity  of  warm  water,  and  slightly  sweetened,  should  be  given  every 
fourth  hour,  but  should  be  withheld  as  soon  as  the  flow  of  milk  occurs. 

Infants  under  the  age  of  one  month  should  nurse  about  every  hour 
by  day  and  at  longer  intervals  by  night,  or  about  ten  times  in  twenty- 
four  hours,  for  the  stomach  of  the  new-born  holds  but  little,  and,  there- 
fore, receives  but  little  at  each  nursing,  and  its  digestion  is  active. 
The  interval  should  be  longer  at  night  than  in  the  daytime,  so  as  to 
allow  the  mother  more  sleep.  In  the  second  month  the  interval  should 
be  about  two  hours,  and  it  should  be  gradually  lengthened  as  the  age 
increases,  so  that  after  the  fourth  month  nursing  should  be  about  every 
third  hour,  and  after  the  sixth  month,  when  the  use  of  some  artificial 
food  is  })roper,  every  fouith  hour. 

The  infant  should  be  habituated  to  nursing  at  regular  intervals,  and 
when  it  is,  it  will  ordinarily  awaken  at  about  the  proper  time.  The 
practice  on  the  part  of  the  mother  of  applying  the  babe  to  the  breast 
Avhenever  it  frets,  and  as  a  means  of  quieting  it,  although  it  have  but 
just  nursed,  is  pernicious  and  should  be  forbidden.  Giving  the  stomach 
no  time  to  rest  or  filling  it  to  repletion,  tends  to  produce  indigestion  and 
diarilioea,  and  to  increase  the  I'retfulness.  The  cause  of  the  fretfulness 
should  be  sought  for,  that  the  proper  measures  may  be  applied.  In 
ignorance  of  the  cause,  it  is  better  to  quiet  the  restlessness  by  canning 
the  child,  or  even  by  rocking  it,  than  to  increase  the  task  of  the  diges- 


AILMENTS    OF    XURSIXG    IXFANTS.  49 

tive  function.  Fretfulness  of  infants  is  often  due  to  colic  or  griping 
produced  by  irritating  products  of  imperfect  digestion  in  the  intestines, 
and  the  addition  of  more  food  has  a  tendency  to  increase  rather  than 
to  diminish  it. 

While  regularity  in  nursing  is  required,  still,  as  M.  Donne  has  said, 
mathematical  exactness  in  this  matter  would  be  ridiculous.  Quiet 
natural  sleep  of  a  -vvell-nourished  infant  should  not  be  interrupted  in 
order  to  give  it  the  breast,  unless  the  sleep  be  unusually  protracted. 
It  will  usually  awaken  when  the  system  requires  more  nutriment.  Ill- 
nourished  infants  often  sleep  but  little,  making  known  their  want  by 
crying  and  fretfulness,  until  they  become  wasted  and  prostrated,  when 
they  are  drowsy  in  consequence  of  passive  congestion  of  the  brain. 
This  drowsiness  is  evidently  a  pathological  symptom.  It  shows  the 
need  of  increased  nutrition.  It  is  due  to  scantiness  of  milk  or  milk  of 
poor  quality,  and  the  infant  should  be  aroused  frequently  for  the  pur- 
pose of  giving  it  nutriment  or  even  stimulants.  The  breast-milk  is 
sufficient  for  its  nutrition  till  the  age  of  six  or  eight  months,  provided 
that  it  is  abundant  and  of  good  quality.  Therefore,  if  the  mother  be 
strong,  and  experience  no  exhaustion  from  suckling,  no  other  nutri- 
ment need  be  given  till  that  age. 

Many  mothers,  hoAvever,  by  the  third  or  fourth  month  of  lactation, 
find  that  they  have  not  sufficient  milk  to  meet  the  wants  of  the  infant. 
The  constant  drain  upon  their  systems  sensibly  impairs  their  health. 
In  such  cases  it  is  proper  to  commence  with  a  little  feeding  from  the 
spoon  or  bottle,  and  increase  the  quantity  given  as  the  infant  grows 
older.  Great  care  is,  however,  requisite  in  the  preparation  of  food  for 
so  young  an  infant,  whose  digestive  organs  are  still  feeble  and  easily 
deranged.  In  the  country,  where  diarrhoeal  affections  and  the  so- 
called  gastric  derangements  are  not  frequent,  the  danger  from  artificial 
feeding  is  less  than  in  the  city,  and  in  the  cool  months  in  the  city  the 
danger  is  less  than  in  the  summer  season.  Infants  of  the  city,  between 
the  months  of  May  and  October,  have  a  strong  predisposition  to  diar- 
rhoeal attacks,  the  result  of  antihygienic  influences  which  surround 
them.  Errors  of  diet  in  their  case  readily  provoke  disease  or  derange- 
ment of  the  digestive  organs,  often  of  a  severe  and  dangerous  fonn. 
Moreover,  experience  has  shown  that  artificial  feeding,  during  the 
period  when  nature  designed  that  they  should  be  nourished  by  lacta- 
tion, very  commonly  produces  in  the  hot  months  more  or  less  vomiting 
and  diarrh(ca,  fallowed  by  emaciation  and  other  evidences  of  mal- 
nutrition. Therefore  an  exception  must  be  made,  in  case  of  the  city 
infant,  as  regards  the  commencement  of  artificial  feeding.  If  it  be 
under  the  age  of  one  year,  it  should  be  nourished  exclusively,  or  almost 
exclusively,  at  the  breast  during  the  hot  montiis,  when  practicable, 
even  if  the  mother  suffer  somewhat  in  her  health  from  the  constant 
drain  u[)on  her  system.  It  should,  however,  receive  the  amount  of 
nutriinent  which  it  requires,  and,  if  there  be  not  sufficient  breast-milk, 
it  will  be  necessary  to  supply  the  deficiency  by  artificial  feeding.  The 
reader  is  referred  to  Chapter  VIII.,  for  facts  relating  to  the  subject  of 
artificial  feeding. 

So  fixed  rule  can  be  stated  in  regard  to  the  time  when  it  is  proper  to 

4 


50  COURSE    OF    LACTATIOX  —  WEAXIXG. 

allow  artificial  food  in  addition  to  the  breast-milk.  While  robust  mothers 
with  abundant  milk  can  satisfy  their  infants  till  the  age  of  six  or  seven 
months,  many  begin  to  feel  the  drain  upon  their  systems  and  have  an 
insufficient  supply  by  the  third  or  fourth  month,  and  it  is  necessary  to 
supplement  the  nursing  by  the  use  of  artificial  food,  a  smaller  or  larger 
quantity,  as  the  case  may  require.  The  deficiency  may  be  supplied  by 
the  use  of  food  prepared  as  recommended  in  Chapter  VIII.  At  six 
months  also,  or  even  at  four  or  five  months,  if  the  infant  appear  ansemic 
and  ill-nourished,  it  may  be  allowed  occasionally  one  or  two  teaspoonfuls 
of  beef-juice,  expressed  from  slightly  boiled  beef,  two  or  three  times 
daily.  At  the  age  of  eight  months,  semi-liquid  food  may  be  given. 
Pap,  prepared  with  stale  bread  or  a  rolled  soda  cracker,  may  also  be 
given  once  or  twice  daily,  between  the  times  of  nursing,  and  occa- 
sionally beef-tea  or  chicken-broth,  thickened  with  cracker  or  bread,  is 
taken  with  relish,  and  if  well  prepared  and  given  no  oftener  than  once 
or  twice  a  day,  it  is  commonly  readily  digested,  while  it  is  highly  nutri- 
tious. If  the  quantity  of  breast-milk  diminish,  as  it  often  does,  toward 
the  close  of  the  first  year,  artificial  food  should  be  given  oftener,  so  as 
to  supply  the  deficiency.  Solid  food  requires  considerable  development 
of  the  digestive  organs  for  its  ready  assimilation.  It  should  not,  there- 
fore, be  given  till  the  close,  or  near  the  close,  of  the  first  year. 

AVeanino;  ought  to  take  place,  as  a  rule,  between  the  ao-es  of  ten  and 
twelve  months.  It  is  well,  if  the  mother's  health  be  good  and  her  milk 
sufficient,  to  defer  weaning  till  the  canine  teeth  appear.  The  infant 
then  possessing  sixteen  teeth,  is  able  to  masticate  the  softer  kinds  of 
solid  food.  Weaning  should  be  gradual.  Mothers  often  speak  of 
weaning  on  a  certain  day.  They  have  given  but  little  artificial  food, 
and  have  suckled  at  regular  intervals,  till  at  a  fixed  time  they  have 
denied  the  breast  altogether.  This  abrupt  change  of  diet  shoidd  be 
discouraged.  It  should  only  be  recommended  under  peculiar  circum- 
stances. It  is  apt  to  derange  the  digestive  organs,  and  it  causes  fret- 
fulness  and  sleeplessness  on  the  part  of  the  infant  for  a  week  or  more. 
Weaning  should  commence  by  feeding  with  a  spoon,  a  little  oftener 
through  the  day,  and  nursing  less,  and  by  discontinuing  the  practice  of 
suckling  at  night.  The  infant  tolerates  this  gradual  change  of  diet, 
while  it  rebels  against  sudden  weaning,  and  by  its  fretfulness  increases 
greatly  the  care  and  trouble  of  the  mother.  Nurslings  in  the  city 
should  not  be  weaned  in  warm  weather,  nor  within  a  month  imme- 
diately preceding  it.  If  the  mother's  health  fail,  or  her  milk  become 
deficient  in  the  summer  months,  so  that  she  cannot  continue  suckling, 
the  infant  should  be  sent  immediately  to  the  country,  or  a  wet-nurse 
be  employed.  Many  lives  are  sacrificed  in  consequence  of  ignorance 
of  the  danger  of  weaning  under  the  circumstances  mentioned.  Severe 
diarrhoea,  inflammatory  or  non-inflammatory,  is  apt  to  result.  This 
subject  will  be  considered  elsewhere. 


QUANTITY    OF    FOOD    REQUIRED.  51 


CHAPTEE   YII. 

QUANTITY  OF  FOOD  REQUIRED  IN  INFANCY  AND  CHILDHOOD. 

The  quantity  and  quality  of  food  required  in  infancy  and  childhood 
is  a  subject  of  the  highest  importance,  and  one  in  regard  to  which  much 
ignorance  prevails.  Children  need  food  more  frequently  than  adults, 
and  they  suffer  more  from  hunger  if  their  meals  are  delayed  beyond  the 
usual  time.  Their  tissues  undergo  more  active  molecular  change  than 
those  of  adults,  so  that  they  need  more  nutriment  for  the  Avaste,  and  they 
require  additional  nutriment  for  the  purposes  of  growth.  It  is  during 
infancy  that  the  most  disastrous  consequences  follow  from  errors  in 
nursing  or  feeding.  Numberless  infants  every  year,  and  especially  in 
the  summer  months,  lose  their  lives  from  this  cause.  Improperly  fed, 
they  soon  show  symptoms  of  indigestion  and 'gastrointestinal  catarrh. 
Their  food,  if  unsuitable  in  quality  or  too  abundant  for  their  digestive 
function,  is  assimilated  with  difficulty,  and  only  in  part.  More  or  less 
of  it  undergoes  fermentation,  producing  lactic  and  butyric  acids,  and 
other  irritating  products,  which  cause  diarrhoea;  and  if  the  error  is  not 
soon  corrected,  the  catarrh  of  the  alimentary  tract  thus  established 
results  in  waste  of  the  tissues,  and,  finally,  a  marasmic  condition  occurs, 
in  which  the  child  perishes,  or  from  which  it  very  slowly  recovers  under 
better  diet  and  improved  liygienic  surroundings. 

So  important  to  the  welfare  of  young  children  is  the  diet,  both  as 
regards  its  quantity  and  quality,  and  the  times  of  feeding,  that  this 
subject  has  attracted  much  attention,  and  many  infant  foods  have  been 
prepared,  which  are  found  in  the  shops.  Both  underfeeding  and  over- 
feeding, as  well  as  the  use  of  improper  diet,  produce  ill-effects.  If 
infants  be  underfed,  they  fret,  and  lose  flesh  and  strength;  if  overfed, 
they  may  vomit  the  surplus  food,  but  if  tliis  do  not  occur,  that  portion 
which  is  not  digested  undergoes  fermentation,  with  the  formation  of  the 
irritating  products  mentioned  above. 

Appreciating  the  importance  of  a  correct  knowledge  of  the  amount 
of  food  recjuired  by  infants,  certain  physicians  have  made  careful  obser- 
vations in  order  to  ascertain  it.  M.  Parrot  (L.  Athre[»sie,  Paris,  1877) 
weighed  infants  before  and  after  eacli  feeding  with  cow's  milk.  The 
number  of  feedings  was  six  in  twenty-four  hours.  His  observations 
were  scarcely  sufficient  in  number  for  accurate  deductions,  but  he  con- 
cluded from  them  that  the  quantity  of  cow's  milk  re(iuire(l  in  twenty- 
four  hours  is  as  follows:  "O.V  ounces  for  the  fust  month;  11)  ounces  for 
the  second,  tliird,  fourth,  and  fifth  months;  and  25  ounces  for  the  sixth 
month."'  This  estimate  is  for  pure  cows  milk  used  without  dihition. 
The  use  of  milk  in  its  pure  state  and  undiluted,  he  considers  preferable 
to  its  dilution.  After  the  sixth  month  he  thinks  that  4^  to  6.\  ounces 
for  eacli  month  should  be  added  to  the  ([uantity  previously  employed. 


52 


QUANTITY    OF    FOOD    REQUIRED. 


Meigs  and  Pepper  mention  the  case  of  an  infant  of  four  months  that 
took  36  ounces  of  breast-milk  daily,  and  another  of  five  to  six  Aveeks, 
that  took  18  to  '2o  ounces  daily.  The  same  authors  cite  the  observa- 
tions of  jNI.  Bouchard,  •who  concludes  from  weighing  infants,  that  while 
the  new-born  require  much  less  breast-milk  than  those  who  are  older, 
20  ounces  daily  are  needed  between  the  ages  of  one  and  three  months, 
23  ounces  after  the  third  month,  27  ounces  after  the  fourth  month,  and 
30  ounces  between  the  ages  of  six  and  nine  months. 

A  few  years  since,  Drs.  Chadbourne,  l*arker,  and  myself,  made  ob- 
servations in  the  New  York  Infant  Asylum  and  New  York  Foundling 
Asylum,  in  order  to  determine  how  much  food  children  required  at 
different  ages.  Those  selected  for  observation  Avere  well  nourished,  and 
they  were  accurately  weighed  before  and  after  each  nursing  or  feeding 
during  twenty -four  hours.  Eleven  infants  under  the  age  of  three  weeks, 
who  nursed,  with  three  exceptions,  twelve  times  in  twenty-four  hours, 
were  found  to  take  in  the  average  in  the  day  and  night  12.55  ounces, 
as  seen  by  the  following  table: 


Table  I — New-born  Infants, 

those  7inder 

i?ie  Af/e 

nf   Three  Weeks. 

Milk  nursed 

in  24  hours. 

Name. 

Age. 

No.  of 
nursings. 

No. 

Quantity  in 

WL'ight 

Quantity  in 

tluidounuus. 

Oz.      Dr. 

1 

Josephine  Foley     . 

17  d. 

11 

10          .V 

9.75 

2 

Henry  Cunningham 

16  d. 

9 

13     5' 

13.24 

3 

Henrv  Jackson 

19  d. 

9 

10    3 

10.07 

4 

ilake       .... 

5d. 

12 

22     7 

22.22 

5 

Henry  Benton 

6  d. 

12 

15     5.V 

15.25 

(5 

Wm.  Fletcher 

5  d. 

12 

10     ll 

9.88 

7 

Nora  Hastie   .... 

14  d. 

12 

17     3" 

16.85 

8 

Carl  Flask      .... 

5  d. 

12 

5    4 

5.37 

'J 

Frederick  Dighle  . 

7  d. 

12 

14    4 

14.08 

10 

Edward  Stace 

6  d. 

12 

8     1 

7.74 

11 

Rosa  Brown   .... 

3  w. 

12 

14     1 

13  68 

The  above  statistics  correspond  with  those  of  other  observers.  They 
show  that  infants  under  the  age  of  three  weeks  take  in  the  average 
about  half  the  milk  required  by  those  over  the  age  of  two  or  three 
months.  After  the  third  Aveek,  the  amount  needed  for  healthy  nutri- 
tion gradually  increases  with  the  progressive  growth  of  the  infant. 


QUANTITY    OF    FOOD    EEQ-VIKED, 


53 


Table  II. — Ages;  Jrom  One  Montli  to   Ten   Months. 


Milk  nursed 

in  24  hours. 

No,  of 

No. 

Name. 

Age. 

nursiugs. 

Quantity  in 
weight. 

Quantity  in 
fluidouuctjs. 

Oz.     Dr. 

1 

Agnes  Siinkle 

6    m. 

8 

2G     U 

25.3 

2 

Je.<.*ie  Bradley 

4    m. 

9 

38       I 

36.8 

3 

Walter  Gorman     . 

3.V  m. 

8 

21     2" 

23  5 

4 

Lottie  Brooks 

7    m. 

10 

27         3.!r 

26.6 

5 

Willie  Loenard 

5J  m. 

11 

28     7" 

28.0 

6 

John  Clay      .... 

5    m. 

10 

29     7 

29  0 

7 

Agnes  W'e;t  .... 

3J  m. 

8 

19     2 

18.G 

8 

Freddy  Van  Buren 

2'  m.  10  d. 

7 

24     4 

23.7 

9 

Eddie  AViUon 

G    m. 

10 

12     4\ 

12.2 

10 

Frank  Smith.         ,         .•       . 

3^  m. 

8 

2(j     7" 

26.1 

11 

Sarah  While. 

4    m. 

8 

23     5 

22.9 

VI 

John  Gatney .... 

9    m. 

8 

24     ]i 

23.4 

13 

Bernhard  Jusejih    . 

7    m. 

8 

27     4' 

26. G 

14 

Thomas  Cole  .... 

6    m. 

10 

26     6^ 

26.0 

15 

A.stie  Russell  .... 

6    m. 

10 

21     6" 

21.1 

16 

Clarence  Humphrey 

1    m.    5d. 

8 

11    n 

10.84 

The  second  series  of  observations  related  to  infants  between  the  ages 
of  one  and  ten  months.  It  was  found  that  they  received  in  the  average 
23.79  fiuidounces  of  breast-milk  in  twenty-four  hours.  The  number 
of  nursings  in  the  day  and  night  varied  from  seven  to  ten.  Therefore 
infants  between  the  age  of  one  or,  perhaps  more  accurately,  two  months 
and  ten  months,  if  they  take  the  breast  eight  times  in  twenty-four 
hours,  receive  three  ounces  at  each  nursing;  if  they  take  the  breast 
twelve  times,  they  receive  two  ounces  each  time. 

The  following  observations  were  made  by  me  in  private  practice.  All 
the  infants  Avere  well  nourished,  having  the  symptoms  of  normal  hearty 
digestion.  An  infant  since  the  age  of  four  weeks,  and  at  the  time  of 
my  observation  six  weeks  old,  took  at  each  feeding  one  and  a  half 
ounces  of  milk,  one  and  a  half  ounces  of  water,  and  one  teaspoonful  of 
Liebij^s  food.  When  three  or  four  weeks  old,  it  took  at  each  feeding 
one  ounce  of  cow's  milk,  one  ounce  of  water,  and  one  teaspoonful  of 
Liebig's  food.  It  was  fed  six  times  in  twenty-four  hours.  A  second 
infant  of  eight  weeks,  large  and  rugged,  took  eight  times  daily  two 
ounces  of  milk,  two  ounces  of  water,  and  two  scant  teaspoonfuls  of 
Liebig's  food.  A  third  infant,  aged  two  months,  took  at  each  feeding, 
eight  times  daily,  one  teaspoonful  of  Liebig's  footl  in  seven  tablespoon- 
fiils  of  milk  and  water  in  ecjual  parts.  A  fourth  infant,  aged  one 
month  and  three  days,  fed  every  hour  the  mother  stated,  but  perhaps 
the  interval  w;is  longer  at  night,  took  in  twenty-four  hours  forty-seven 
tablespoonfuls  of  the  following  mixture,  or  about  two  tablespoonfuls  at 
each  feeding:  one  heaped  taltk-spoonful  of  IJonlen's  condensed  milk,  one 
tablespoonfid  of  lime  water  and  ten  of  water.  A  fifth  iid'aiit,  which 
seems  to  have  been  a  very  hearty  feeder,  aged  si.\  nioiitlis.  took  at  each 
feeding  and  nine  times  in  twenty-four  hours,  peptonized  milk  prepared  as 


54  QUANTITY    OF    FOOD    REQUIRED. 

follows  :  One  tablespoonful  of  peptogenic  powder  (Faivcliild's,  designed  to 
peptonize  the  milk),  four  tablespoonfuls  of  milk,  four  of  water,  and  one 
of  cream.  The  large  quantity  of  nine  tablespoonfuls  at  each  feeding 
did  not  seem  to  produce  any  gastric  distress. 

The  above  observations  are  designed  to  show  the  average  amount  of 
milk  required  by  the  infant,  but  some  infants,  like  adults,  need  consider- 
ably more  food  than  others,  and  the  infantile  stomach  is  so  distensible 
that  it  holds  more  without  discomfort  than  would  seem  possible  in 
viewing  it  in  the  cadaver.  Thus  the  infant  of  four  months,  observed  by 
Meigs  and  Pepper,  took  thirty-six  ounces  of  breast-milk  in  twenty-four 
hours,  without  apparent  discomfort,  and  with  a  healthy  and  robust  de- 
velopment of  his  system,  Avhile  one-third  less  would  have  been  sufficient 
for  another  infant.  Of  course,  if  the  breast-milk  furnished  to  the  infant  be 
too  watery  and  deficient  in  nutritive  properties,  or  if  the  cow's  milk  with 
which  it  is  fed  be  too  much  diluted,  the  quanity  of  food  which  it  takes 
and  requires  will  be  in  excess  of  the  average  quantity.  Thus  the  infant 
of  six  months  alluded  to  above  that  took  four  tablespoonfuls  of  milk, 
four  of  water,  and  one  of  cream,  Avould  probably  have  done  as  well  with 
two  less  tablespoonfuls  of  water,  since  in  the  smaller  quantity  it  would 
have  taken  the  same  amount  of  nutriment.  The  importance  of  the 
above  observations  is  apparent,  for  they  enable  us  to  determine 
approximately  hoAV  much  food  should  be  given  at  each  feeding  to 
infants  that  are  unfortunately  deprived  of  the  breast-milk.  The  quan- 
tity required,  as  indicated  by  these  observations,  may  be  stated  as 
folloAvs :  Under  the  age  of  three  weeks,  from  one  ounce  to  one  and  a 
half  ounces  of  cow's  milk,  diluted  and  ])repared  after  it  is  measured,  so 
as  to  resemble  so  far  as  possible  breast-milk,  should  be  given  at  each  of 
the  twelve  daily  feedings.  The  quantity  should  be  gradually  increased 
as  the  infant  grows  older  until  the  age  of  three  months,  when  three 
ounces  should  be  given  at  each  of  the  eight  feedings.  It  should  be 
properly  diluted  after  it  is  measured.  Some  infants  do  not  seem  to 
require  an  increase  of  this  amount,  but  others  who  are  hearty,  need 
more.  Thus  infant  No.  2,  in  the  second  table,  at  the  age  of  four 
months,  took  in  the  average  four  ounces  of  breast-milk  at  each  of  the 
nine  nursings  in  tAventy-four  hours.  At  the  age  of  six  months,  the 
infant  should  be  fed  every  three  hours,  and  four  ounces  of  milk  may  be 
given  at  each  feeding,  in  order  to  insure  a  .sufficient  quantity.  Some 
require  less  than  this  amount,  and  occasionally  one  needs  a  little  more, 
as  four  and  a  half  or  even  five  ounces. 


QUANTITY    OF    FOOD    EEQUIEED. 


55 


Table  III — Observations  lielating  to  the  Diet  during  Twenty-four  Hours,  of 
Tweiity-eififit  Healthy  CliUdren,  hetiueen  the  Ages  of  Two  and  Three  Years, 
juith  an  Average  Age  of  Two  Years  Eight  Months. 


Total  amount. 

Average 

for  each. 

Breakfast: 

Bread 

.         •         • 

Gibs. 

4  oz. 

1  dr. 

3.5 

oz. 

Butter     . 

13  oz. 

5  dr. 

0  45 

oz. 

Milk        . 

Dinner. 

22  lbs. 

14  oz. 

2  dr.i 

12.7 

fl.  OZ. 

Meat 

8  lbs. 

0  oz. 

5  dr. 

4.6 

OZ. 

Potatoes 

G  lbs. 

13  oz. 

7  dr. 

3.9 

oz. 

Milk       . 

Supper. 

17  lbs. 

9  oz. 

7  dr. 

9.4 

fl.   OZ. 

Milk       . 

19  lbs. 

12  oz. 

Idr. 

10.5 

fl   oz. 

Bread      . 

7  lbs. 

1  oz. 

2  dr. 

4.0 

oz. 

Butler     . 

14  oz. 

7  dr. 

0.53 

oz. 

DAILY  AVERAGE  FOR  EACH  CHILD. 


Bread 
Butler 
Meat  (beef) 
Potatoes 
Milk  . 


7.5  oz.  avoir. 
0  98  oz.       " 

4.6  oz.      " 
3  9    oz.       " 

32.6    fl.  oz. 


Table  IV. — Observations  tcpon   Twelve  Children  between  the  Ages  of  Three  and 
Six   Years:    Average  Age,  Four   Years   Ten  Months. 


T..tal  aniuiint. 

Average  for  each. 

Breakfa.st. 

Bread 

4  lbs.    6  oz. 

3^  dr.  • 

5.86    oz. 

Butter 

5  oz. 

2    dr. 

0.427  oz. 

Milk 

Dinner. 

280  fl.  oz. 

23  3  fl.  oz. 

Beef 

9  lbs.     1  oz. 

3    dr. 

12.1  oz. 

Bread 

lib.      0  oz. 

1    dr. 

1.6  oz. 

Ki.e 

9  lbs.  12  oz. 

7    dr. 

13.0  oz. 

Milk 

112  fl.  oz. 

9.3  fl.  oz. 

Butter 

Supper. 

2  oz. 

21  dr. 

Bread 

2  lbs.    4oz. 

Udr. 

3.0  oz. 

Butter 

5  oz. 

5idr. 

Milk 

192  fl.  oz. 

16.0  li.  oz. 

Milk, 
li.ef  . 
Bice   . 
Bivad 
Butler 


daily  average  k 


)R    EACH    CHILD. 


48.6    fl.  oz. 
12.1    oz.  avoir. 
13  0    oz.      " 
10.3    oz.      '• 
1.08  oz.      " 


■  354.6  fluidounces. 


56 


QUANTITY  OF  FOOD  REQUIEED. 


Tablk  V. — Obserrntions  Relatmg  to  t/ie  Diet  of  Twenty-four  Children,  Twelve 
Boys,  Twelve  Girls,  between  the  Ages  of  Four  Years  and  Ten  Years:  Average, 
Six  Years  Ten  Mont /is. 


Total  amount. 

Average  for  each. 

Breakfast. 

Bread     . 

7  lbs.  13  oz. 

3 

dr. 

5.21 

oz. 

Butter     . 

12  oz. 

3i 

dr. 

0  51 

oz. 

Milk       . 

Dinner. 

348  fl.  oz. 

14.5 

11.  oz. 

Koast  beef 

18  lbs.  11  oz. 

0 

dr. 

12.46 

oz. 

Potatoes 

15  lbs.    8  oz. 

3 

dr. 

10.30 

oz. 

Bread      . 

1  lb.      6  oz. 

h 

dr. 

0.'J2 

oz. 

Milk 

192  11.  oz. 

80 

fl    oz. 

Butter    . 

Supper. 

^ 

dr. 

OOl'J 

oz. 

Bread     . 

6  lbs.    2  oz. 

3  J 

dr. 

4.1 

oz. 

Milk       . 

384  11.  oz. 

10.0 

fl.  oz. 

Butter    . 

11  oz. 

"^2 

dr. 

0.16 

oz. 

DAILY  AVERAGE  FOR  EACH  CHILD. 


Koast  beef 
Bread        . 
Potatoes  . 
Butter 
Milk 


12.46  oz. 
10.23  oz. 
10.3  oz. 
0.99  oz. 
38.5    fl.  oz. 


Compare  the  above  observations  with  those  of  Professor  Dalton,  who 
estimates  tliat  a  healthy  adult  taking  active  exercise  requires  each  day — 

Meat 16    oz. 

Bread 19    oz. 

Butter 3i  oz. 

"Water  ...........  62    oz. 


while  one  leading  a  sedentary  life  needs  considerably  less. 

It  will  be  seen  by  the  above  tables,  that  even  more  food  appears  to 
be  needed  during  the  period  of  childhood  than  in  adult  life.  We  Avould 
suppose  this  to  be  so  without  statistical  evidence,  for  the  active  exercise 
and  rapid  and  progressive  growth  of  this  period  necessarily  require  a 
large  amount  of  nutriment.  Moreover,  while  adults  do  well  with  solid 
food  and  water,  statistics  show  that  the  best  diet  for  children  who  have 
passed  beyond  infancy,  is  one  of  milk  with  solid  food,  for  at  least 
breakfast  and  supper. 

Although  we  are  able,  by  observations,  to  determine  the  average 
amount  of  food  required  in  twenty-four  hours,  by  children  of  various 
ages,  it  would  be  wrong  to  limit  the  diet  to  a  fixed  quantity,  for  some 
need  more  than  others.  A  child  should  never  go  hungry  after  a  meal. 
In  some  of  the  best  conducted  institutions  of  New  York,  the  children 
eat  of  plain  food  all  that  they  desire  at  each  meal,  while  in  other  insti- 
tutions the  food  at  supper  is  limited,  but  is  abundant  at  the  other  meals. 
As  children  go  to  bed  so  soon  after  supper,  it  is  proper  to  have  this 
meal  light,  and  of  such  food  as  is  easily  digested. 


ARTIFICIAL    FEEDING. 


57 


CHAPTER    YIII. 

AKTIFICIAL  FEEDING. 

Occasionally  the  mother  is  unable  to  suckle  her  infont,  and  a  hired 
wet-nurse  cannot  be  or  is  not  obtained.  Artificial  feeding  is  then 
necessary.  In  the  large  cities,  this  mode  of  alimentation  for  young 
infants  should  always  be  discouraged,  for  it  frequently  ends  in  death, 
preceded  by  evidences  of  faulty  nutrition.  A  considerable  proportion 
of  those  nourished  in  this  manner  thrive  during  the  cold  months,  but 
on  the  approach  of  the  warm  season  they  are  the  first  to  be  affected 
with  diarrhoea  and  other  symptoms  indicating  derangement  of  the  di- 
gestive function.  In  New  York  City  a  large  proportion  of  the  artificially 
fed  infants,  who  enter  the  summer  months,  die  before  the  return  of  cook 
weather,  unless  saved  by  removal  to  the  country.  In  the  country,  and 
in  the  small  inland  cities,  the  results  of  artificial  feeding  are  much  more 
favorable.  In  elevated  farming  sections,  on  account  of  the  salubrity  of 
the  air,  and  the  facility  with  which  milk,  fresh  and  of  the  best  quality, 
is  obtained,  artificial  feeding  is  attended  by  much  less  risk  than  in  the 
cities. 

Young  infants,  fed  by  the  hand,  obviously  require  food  prepared  so 
as  to  resemble  as  closely  as  possible  human  milk  in  its  composition. 
Woman's  milk  in  health  is  always  alkaline.  It  has  a  specific  gravity 
of  1031.7;  cow's  milk  has  a  specific  gravity  of  1029.  That  of  cows 
stabled  and  fed  upon  other  fodder  than  hay  or  grass  is  usually  decidedly 
acid.  That  from  coavs  in  the  country  with  good  pasturage  is  said  to  be 
alkaline,  but  in  two  dairies  in  Central  New  York  a  hundied  miles  apart, 
in  midsummer,  with  an  abundant  pasturage,  two  competent  persons 
whom  I  requested  to  make  the  examinations  found  the  milk  slightly 
acid  immediately  after  the  milking  in  all  the  cows. 

The  following  results  of  a  large  number  of  analyses  of  woman's  and 
cow's  milk,  made  by  Konig  and  (pioted  by  Leeds,  and  of  several  of  the 
best  known  and  most  used  prejjarations  designed  by  their  inventors  to 
be  substitutes  for  human  milk,  show  how  fjir  these  substitutes  resemble 
the  natural  aliment  in  their  chemical  characters  : 


\\ 

'onian'g  milk 

Cow's  milk. 

Mean. 

MiiiiDiuni 

Muxinium 

Mean. 

Minininni. 

Muxininni. 

Water 

87  00 

8.3  0 

90  90 

87.41 

80  32 

91.50 

Total  solids      . 

12!)1 

9  10 

1G31 

12.59 

8.50 

19.(i8 

Fat. 

3  no 

1.71 

7.00 

8.(iO 

1.15 

7.09 

Milk-?ugar 

0  04 

4.11 

7.80 

4  92 

3.20 

6.(57 

Casein 

o.(;:? 

0  18 

1.90 

3.01 

1.17 

7.40 

Albumen 

L81 

0  39 

2  3') 

0  75 

021 

6.04 

Albuminoids    . 

l.W 

0.57 

4.2o 

3  7<i 

1.38 

12.44 

Ash 

0.49 

0.14 

0  70 

0.50 

0.87 

58 


ARTIFICIAL    FEEDING. 


The  following  analyses  of  the  foods  for  infants  found  in  the  shops,  and 
which  are  in  common  use,  were  made  by  Leeds,  of  Stevens's  Institute. 


Farinaceous  Foodfs. 


1. 

2. 

3 

4. 

5. 

6. 

Blair's 

HubbeU's 

Imperial 

Ridge's 

"A  B.C" 

Robinson's 

wheat  food. 

wheat  food 

granum. 

food. 

Cereal  milk 

barley. 

Water 

9.85 

7.78 

5  49 

9.28 

9.33 

10  10 

Fat      .... 

1.56 

0.41 

1.01 

0.68 

1.01 

0.97 

Grape-sui;ar 

1.75 

7  56 

Tnice. 

2.40 

4.60 

3  08 

Cane-sugar 

1.71 

4.87 

Trace. 

2  20 

15  40 

0.90 

Starch 

64.80 

67.60 

78.93 

77  96 

58.42 

77.76 

Soluble  carbohydrates 

13.69 

1429 

3  56 

5  19 

20.00 

4  11 

Albiimindids 

7.16 

10.18 

10.51 

9.24 

11  08 

5.13 

Gum,  cellulose,  etc.     . 

2.94 

Undeterm'd 

0.50 

1.16 

1.93 

Ash      .... 

1.06 

1.00 

1.16 

0.60 

1.93 

Liebig's  Foods. 


Keas- 

Savory 

Baby 

Mellin's. 

Hawley's 

Horlick's 

bev   and 

and 

Biiliy  sup 

sup 

Jiatti- 

Moore's. 

Xu.  1. 

No.  2. 

son's. 

"Water 

5  00 

6.60 

3.39 

27.95 

8.34 

5.54 

11.48 

Fat     .... 

0.15 

0.61 

0.08 

None. 

040 

1.28 

0.62 

Grape-sugar 

44.69 

40.57 

34.99 

36.75 

20.41 

2.20 

2  44 

Cane-sugar 

3.51 

3.44 

12.45 

7.58 

9.08 

11.70 

2.48 

Starch 

None. 

10.97 

None. 

None. 

36.36 

61.99 

51.95 

Soluble  carbohydrates 

85.44 

76.54 

87.20 

71.50 

44.83 

14.35 

22.79 

Albuminoids 

5.95 

5.38 

6.71 

None. 

9.63 

9.75 

7.92 

Gum,  cellulose,  etc.    . 

0.44 

7  09 

5. '24 

Ash    .... 

1.89 

1.50 

i.28 

0.93 

0.89 

Undeterm'd 

1.59 

Milk  Foods. 


Nestle's. 

Anglo-Swiss. 

Gerber's. 

American-Swiss. 

Water 

4.72 

6.54 

6  78 

5  68 

Fat 

1.91 

2.72 

2.21 

6.81 

Grape-.=  ugar  and  milk-sugar 

6  92 

23.29 

6.06 

5.78 

Cane-sugar     .... 

32.93 

21.40 

80.50 

36.43 

Starch     

40.10 

34.55 

38.48 

30  85 

Soluble  carbohydrates    . 

44.88 

46.43 

44.76 

45.35 

Albuminoids. 

8. -23 

10.26 

9.56 

10.54 

Ash 

1.59 

1.20 

1.21 

1.21 

It  is  seen  by  examination  of  the  analyses  of  the  above  foods  that  all 
except  such  as  consist  largely  or  wholly  of  cow's  milk  differ  widely 
from  human  milk  in  their  composition,  and  although  some  of  them — as 
the  Liebig  preparations,  in  which  starch  is  converted  into  glucose  by 
the  action  of  the  diastase  of  malt — may  aid  in  the  nutrition  and  be 
useful  as  adjuncts  to  milk,  physicians  of  experience  and  close  observa- 
tion agree  that  when  breast-milk  fails  or  is  insufficient,  our  main  re- 


goat's    MILK.  59 

liance  for  the  successful  nutrition  of  the  infant  must  be  on  animal  milk. 
Nestle's  food,  which  consists  of  wheat  flour,  the  yelk  of  egg,  condensed 
milk,  and  sugar,  and  -which  has  been  so  largely  used  in  this  country 
and  in  Europe,  is  probably  beneficial  mainly  from  the  large  amount  of 
Swiss  condensed  milk  in  its  composition. 

Cow's  milk  being  readily  obtained,  is  commonly  used  as  a  substitute 
for  human  milk,  compared  with  which  it  contains  less  water  and  sugar, 
but  more  butter,  casein,  and  salts.  Its  composition,  however,  varies 
considerably,  according  to  the  food  of  the  cow  and  other  circumstances. 
The  variations  in  the  milk  of  the  cow,  according  to  the  nature  of  its 
food,  have  been  considered  in  a  preceding  chapter.  It  has  been  stated, 
also,  that  the  milk  first  obtained  in  milking  is  most  watery,  since  it  is 
longer  secreted  than  the  last  milk,  or  the  "stripping."  The  stall-fed 
cow  gives  milk  that  is  moiC  acid  than  that  of  the  pasture-fed  cow. 
Again,  the  milk  in  the  first  months  after  calving  is  richer  than  after 
the  lapse  of  several  months. 

It  is  obvious  from  the  above  facts,  that  the  analyses  of  different 
specimens  of  cow's  milk  must  differ  greatly,  and  the  same  is  true  of  the 
milk  of  the  goat  and  ass,  and  probably  of  the  ewe.  In  fact,  different 
samples  of  the  milk  of  the  same  animal  may  differ  more  from  each 
other,  in  their  chemical  character,  than  the  average  milk  of  one  animal 
from  that  of  another. 

The  milk  of  the  goat  and  that  of  the  ass  have  been  recommended  as 
food  for  infants  in  preference  to  cow's  milk,  on  the  ground  that  they 
more  nearly  resemble  human  milk.  But  by  reference  to  the  foregoing 
table,  it  will  be  seen  that  more  importance  has  been  attached  to  this 
supposed  resemblance  than  the  facts  justified.  Neither  tlie  milk  of  the 
ass  nor  goat,  so  far  as  its  chemical  character  is  concerned,  would  seem 
to  possess  any  marked  advantage  over  cows  milk.  The  ass's  milk  is 
procured  with  difficulty,  and  is  seldom  used.  An  objection  to  goat's 
milk  is  the  unpleasant  odor  which  it  often  possesses,  due  to  the  presence 
of  hircic  acid.  It  is  stated,  however,  by  Parmentier,  that  this  odor  is 
only  noticed  in  the  milk  of  goats  that  have  horns.  An  important  ad- 
vantage, in  the  city,  in  the  use  of  goat's  milk,  is  that  the  animal  can 
be  kept  at  little  expense,  so  that  even  poor  families  who  are  not  able  to 
purchase  and  feed  a  cow,  can  generally  possess  a  goat  from  which  fresh 
milk  can  be  obtained  at  any  time.  Preference  is  to  be  given  to  goat's 
milk,  when  fresh,  over  cow's  milk  brought  from  the  country,  perhaps 
Avatered  on  the  way,  sevei'al  hours  old  when  received,  and  in  commenc- 
ing fermentation.  But  cows  milk  of  good  quality  and  free  froui  fer- 
mentative changes,  is  probably  not  inferior  to  goat's  milk  as  a  food  for 
infants,  and  from  its  abundance  it  must  continue  to  be  in  common  use 
for  this  purpose. 

If  the  mother's  milk  fail,  or  become  unsuitable  from  ill-health  or 
pregnancy,  and  on  account  of  family  circumstances  a  wet-nurse  cannot 
be  cm))loye(l,  tiie  important  duty  devolves  uj)on  the  ])hysician  of  de- 
ciding liow  the  infant  should  be  fed.  Shall  one  of  the  numerous  foods 
in  the  shops  be  employed — some  of  which,  as  Liebig's,  have  real  merit — 
or  shall  milk  be  used  as  the  sole  food,  or  bo  used  in  combination  with 
some  other  food,  and  if  so  used,  what  shall  be  the  mode  of  combination 


60  ARTIFICIAL    FEEDINa. 

and  preparation?  In  order  to  solve  this  problem  it  will  be  well  to 
recall  to  mind  the  part  performed  in  the  digestive  function  by  the  dif- 
ferent secretions  which  digest  food : 

1st.  The  saliva  is  alkaline  in  health.  It  converts  starch  into  glucose 
or  grape-sugar.  It  has  no  effect  upon  fat  or  the  protein  group.  It  is 
the  secretion  of  the  parotid,  submaxillary,  and  sublingual  glands,  which 
in  infimts  under  the  age  of  three  months  are  very  small,  almost  rudi- 
mentary. The  power  to  convert  starch  into  sugar  possessed  by  saliva 
is  due  to  a  ferment  which  it  contains  called  ptyalin. 

2d.  The  gastric  juice  is  a  thin,  nearly  transparent,  and  colorless 
fluid,  acid  from  the  presence  of  a  little  hydrochloric  acid.  It  produces 
no  change  in  starch,  grape-sugar,  or  the  fats,  except  that  it  dissolves 
the  covering  of  the  fiit-cells.  Its  function  is  to  convert  the  proteids  into 
peptone,  which  is  ejected  by  its  active  principle,  termed  pepsin. 

3d.  The  bile  is  alkaline  and  it  neutralizes  the  acid  product  of  gastric 
digestion.  It  has  no  effect  on  the  proteids.  It  forms  soaps  Avith  the 
fatty  acids,  and  has  a  slight  emulsifying  action  on  fat.  Tlie  soaps  are 
said  to  promote  the  emulsion  of  fat.  Their  emulsifying  power  is 
believed  to  be  increased  by  admixture  with  the  pancreatic  secretion. 
Moreover,  the  absorption  of  oil  is  facilitated  by  the  presence  of  bile 
upon  the  surface  through  which  it  passes. 

4th.  The  pancreatic  juice  appears  to  have  the  function  of  digesting 
whatever  alimentary  substance  has  escaped  digestion  by  the  saliva, 
gastric  juice,  and  bile.  It  is  a  clear,  viscid  liquid  of  alkaline  reaction. 
It  rapidly  changes  starch  into  glucose.  It  converts  proteids  into  pep- 
tones and  emulsifies  fats.  While  the  gastric  juice  requires  an  acid 
medium  for  the  performance  of  its  digestive  function,  the  pancreatic 
juice  requires  one  that  is  alkaline.  These  important  facts  should  be  borne 
in  mind,  that  such  a  mistake  as  prescribing  pepsin  with  chalk  mixture, 
or  the  extractum  pancreatis  Avith  dilute  muriatic  acid,  may  be  avoided. 

5th.  The  intestinal  secretions  are  mainly  from  the  crypts  of  Lieber- 
kiihn,  and  their  action  in  the  digestive  process  is  probably  compara- 
tively unimportant,  but  in  some  animals  they  have  been  found  to  digest 
starch.  It  Avill  be  observed  that  of  all  these  secretions  that  which 
digests  the  largest  number  of  nutritive  principles  is  the  pancreatic.  It 
digests  all  those  which  are  essential  to  the  maintenance  of  life  except 
fat,  and  it  aids  the  bile  in  emulsifying  fat. 

It  is  seen  from  this  brief  revioAv  of  the  action  of  the  digestive  fer- 
ments, that  starch  is  digested  in  only  a  very  small  quantity  by  infants 
under  the  age  of  three  months;  and,  therefore,  that  those  foods  wliich 
consist  largely  of  starch  afford  but  little  nutriment  at  this  age.  The 
impropriety  also  of  administering  for  days  large  quantities  of  an  alkali, 
as  is  frequently  done,  is  apparent  from  the  above  statement  in  regard 
to  the  action  of  pepsin,  since  it  may  retard  or  prevent  gastric  digestion. 

In  1882,  a  conference  was  held  in  Salzburg,  Germany,  of  physicians 
from  various  parts  of  the  German  Empire,  known  througliout  the  Avorld 
as  specialists  in  the  diseases  of  chihlren.  The  purpose  of  the  conven- 
tion was  to  discuss  the  diet  of  infancy  and  childhood.  They  agreed 
that  animal  milk  is  the  best  substitute  for  human  milk  in  the  feeding 
of  infants,  either  as  the  main  food  or  as  the  basis  of  the  food  em- 


PEPTONIZED    MILK.  61 

ployed.  Useful  as  some  of  the  preparations  of  the  shops  are  as  adjuvants, 
nevertheless,  experience  shows  the  soundness  of  the  opinion  expressed 
by  the  conference,  and  yet  feeding  with  animal  milk  of  the  best  quality 
must  be  carefully  managed,  or  it  will  be  found  to  disagree  with  the  feeble 
and  readily  disturbed  digestive  function  of  the  infant. 

Milk  should  always  be  given  at  a  uniform  temperature  of  about 
99°.  Employed  habitually  too  hot  or  too  cold,  it  frequently  produces 
stomatitis,  or  a  more  serious  disease  of  the  digestive  organs. 

Infants  under  the  age  of  ten  months  should  nurse  from  the  nursing 
bottle,  and  this  as  soon  as  used  should,  with  the  India-rubber  top  and 
attachment,  be  immersed  in  a  quart  or  two-quart  bowl  of  cold  Avater,  to 
which  a  tcaspoonful  of  sodium  bicarbonate  has  been  added,  and  water 
should  be  drawn  through  the  tube  and  nipple  by  suction  with  the  mouth. 

Cow's  milk,  though  possessing  nearly  the  same  composition  as  human 
milk,  nevertheless  behaves  difierently  in  some  respects  in  digestion. 
The  casein  of  human  milk  coagulates  in  light  flocculi  in  the  stomach 
of  the  infant,  so  as  to  be  readily  acted  on  by  the  digestive  ferments, 
while  that  of  cow's  milk  forms  large  and  firm  coagula,  which  are  with 
difficulty  digested.  The  irritating  products  of  a  slow  and  imperfect 
digestion  frequently  cause  colic,  and  fever,  with  more  or  less  intestinal 
catarrh.  Coav's  milk,  therefore,  disagrees  with  many  infjints,  who 
suffer  from  indigestion  in  consecjuence  of  the  feeding,  whose  stools  show 
masses  of  partly  digested  casein,  with  abundant  mucus,  Avho  fret  from 
gastro-intestinal  uneasiness,  and  vomit  often,  and  do  not  thrive  like 
infants  nourished  at  the  breast.  Therefore,  the  profession  have  lone 
felt  the  need  of  some  modification  of  cow's  milk  so  that  it  more  closely 
resembles  human  milk  in  its  digestion.  This  has  in  a  measure  been 
accomplished  by  the  process  known  as  peptonizing,  by  which  the 
casein  is  digested,  or  so  fiir  digested  that  it  coagulates  in  "ilakes.  Pep- 
tonized milk,  or  milk  which  is  partially  digested  by  artificial  means,  is 
prepared  by  the  action  upon  it  of  extractum  pancreatis  and  sodium 
bicarbonate.  We  may  here  briefly  state  the  method.  Extractum 
pancreatis  oj,  «ind  sodium  bicarbonate  oij,  are  added  to  one  gill  of  tepid 
water,  and  this  is  mixed  with  one  pint  of  tepid  milk  as  fresh  as  possible. 
The  mixture  is  allowed  to  stand  in  water  liaving  a  temperature  of  about 
100°  to  110°,  for  half  an  hour,  or  even  one  hour,  if  it  do  not  become 
bitter.  After  the  half  hour  the  milk  should  be  freijuently  tasted,  and 
if  it  be  in  the  least  bitter,  it  should  be  immediately  removed  from  the 
heat,  and  what  is  not  used  should  be  placed  upon  ice.  If  it  be  fully 
digested,  it  is  too  bitter  for  use.  If  it  be  slightly  digested,  the  bitter- 
ness is  not  appreciable,  or  is  so  slight  that  it  is  readily  taken  by  the 
infant,  and  the  casein  coagulates  in  flakes  instead  of  large  coagula. 
Observations  in  feeding  in  the  New  York  Foundling  Asylum,  appeared 
to  show  tliat  infants  under  the  age  of  three  months  did  better,  if  one 
pint  of  Avater  instead  of  one  gill  Avere  used  Avith  the  pint  of  milk. 
I'rof.  Leeds  recommends  the  folloAving  method  as  an  inq)rovenient. 
In  his  opinion  it  produces  milk  so  closely  resembling  breast-milk  in  its 
chemical  character  and  behavior,  that  he  designates  it  humanized  cow's 
milk: 


62  ARTIFICIAL    FEED  IX  G. 

"  1  gill  of  cow's  milk. 

1  gill  of  water. 

2  tablespoonfuls  of  rich  cream. 
200  grains  of  milk-sugar. 

\\  grains  of  extractum  pancreatis. 
4    grains  of  sodium  bicarbonate  " 

"Put  this  in  a  nursing-bottle,  place  the  bottle  in  water  made  so 
warm,  that  the  Avhole  hand  cannot  be  held  in  it  without  causing  pain 
longer  than  one  minute  Keep  the  milk  at  this  temperature  for  exactly 
twenty  minutes.  The  milk  should  be  prepared  just  before  using." 
Messrs.  Fairchild  have  prepared  according  to  the  above  formula  what 
they  designate  a  peptogenic  powder  in  a  can  accompanied  by  a  measure 
which  holds  sufficient  for  peptonizing  two  ounces  of  milk  with  half  an 
ounce  of  cream. 

Peptonized  milk  is  an  useful  addition  to  the  dietetic  preparations  for 
infants.  By  peptonizing  is  accomplished  what  physicians  have  long  felt 
the  need  of,  to  wit:  a  mode  of  preparing  cow's  milk,  so  that  its  casein, 
coagulates  in  flakes  like  that  of  human  milk.  Milk  employed  for  this 
purpose  should  be  as  fresh  as  possible,  but  unfortunately  in  hot  weather 
when  there  is  most  need  of  having  a  food  for  artificially  fed  infants, 
which  bears  the  closest  possible  resemblance  to  human  milk,  in  order 
to  prevent  the  summer  diarrhoea,  much  of  the  cow's  milk  wlien  it 
reaches  the  cities  twenty-four  hours  after  the  milking,  has  begun  to  un- 
dergo fermentation,  and  is  therefore  unsuitable  for  peptonizing,  though 
employed  for  this  purpose.  This  is  probably  one  of  the  chief  causes  of 
the  fact  that  peptonized  milk  not  unfrequently  disappoints  our  expecta- 
tions, so  that  we  find  that  the  patient  does  better  if  fed  with  condensed 
milk  or  one  of  the  foods  of  the  shops.  The  peptonizing  of  milk  rests 
on  a  scientific  basis,  and  as  clinical  experience  thus  far  has  demon- 
strated the  usefulness  of  milk  prepared  in  this  manner  in  the  feeding  of 
infants  in  a  certain  proportion  of  cases,  it  will  probably  continue  to  be 
regarded  as  one  of  the  best  substitutes  for  breast-milk.  It  has  also  been 
found  useful  for  children  with  feeble  digestion,  who  have  passed  beyond 
the  age  of  lactation. 

If  for  any  reason  cow's  milk  be  not  peptonized,  an  alkali  added  to 
it  retards  coagulation,  and  tends  to  prevent  the  formation  of  large  and 
thick  curds.  If  therefore  tlie  child  vomit  curds,  or  pass  fragments 
of  them  in  the  stools,  lime  water  may  be  added,  or  the  carbonate  of 
sodium  as  recommended  by  Vogel,  who  dissolves  one  drachm  of  the 
carbonate  in  six  ounces. of  water,  and  adds  a  teaspoonful  to  the  milk  at 
each  meal.  A  more  effectual  way  to  prevent  the  formation  of  large 
and  firm  caseous  coagula,  is  to  mix  Avith  the  milk  some  bland  and  easily 
digested  farinaceous  food,  as  Liebig's  Avhicii,  by  mechanically  separating 
the  caseous  particles,  prevents  the  formation  of  large  masses;  and 
which,  while  it  has  nutritive  properties,  dilutes  the  milk  and  enables 
the  digestive  fluids  to  act  more  readily  upon  it. 

It  is  known  that  infants  prior  to  the  third  month  can  digest  only 
a  very  small  amount  of  starch,  since  the  salivary  and  pancreatic  glands, 
whose  secretions  convert  starch  into  glucose,  a  necessary  change  in 
digestion,  are  almost  rudimentary  in  the  first  months  of  infancy.     In 


liebig's  food,  63 

a  monograph  relating  to  Infant  Diet  Avritten  by  Professor  A.  Jacobi, 
and  revised,  enlarged,  and  adapted  to  popular  reading  by  Dr.  jNIary 
Putman  Jacobi,  it  is  stated  that  the  parotid  glands  which,  together, 
■\veio"h  80  grains  at  fifteen  months,  and  120  grains  at  tAvo  years,  weigh 
but  34  grains  at  the  age  of  one  month.  In  several  instances  we 
weighed  the  pancreas  taken  from  the  bodies  of  infants  who  had  died 
under  the  age  of  six  months  in  the  New  York  Inihnt  Asylum.  Its 
Aveio-ht  was  very  different  in  those  whose  ages  were  about  the  same;  in 
several  under  the  age  of  four  months  it  was  less  than  one  drachm,  and 
in  some  more  than  one  drachm ;  but  in  no  instance  did  it  reach  two 
drachms.  The  submaxillary  and  sublingual  glands,  Avhich  also  secrete 
a  licjuid  that  is  designed  to  convert  starch  into  glucose,  are  compara- 
tively insignificant  in  young  infants,  so  that  the  combined  action  of  the 
parotid,  submaxillary,  sublingual,  and  pancreatic  secretions,  must  be 
inadequate  for  the  sacch.arification  of  the  starch  which  ordinary  farina- 
ceous food  contains,  during  the  first  three  or  four  months  of  infancy. 

But  it  is  now  ascertained  that  the  salivary  and  pancreatic  secretions 
are  not  the  only  agents  by  which  starch  is  digested.  The  mucous 
surface  furnishes  an  "epithelial  ferment,  which  assists  in  the  change, 
so  that  the  secretions  from  the  buccal  and  intestinal  surfiices  materially 
aid  in  the  digestion."  {Revue  des  Sciences  Med.,  1879,  by  Charles 
Richert;  also  remarks  by  Professor  Flint,  Jr.,  in  Physiol,  of  3Ian.) 

It  appears,  therefore,  that  young  infants  are  able  to  digest  a  certain 
amount  of  starch,  but  a  much  smaller  proportion  than  those  who  are 
older;  and  the  preparation  of  a  farinaceous  food  in  whicli  saccharifi- 
cation  of  the  starch  is  effected  by  a  chemical  process,  and  the  delicate 
and  easily  deranged  digestive  organs  of  the  infant  relieved  of  the  task, 
has  long  been  a  desideratum. 

The  late  Baron  Liebig,  who  devoted  considerable  time  in  the  last 
years  of  his  life  to  the  study  of  the  food  of  infants,  prepared  such  an 
article,  widely  and  favorably  known  as  Liebigs  food.  It  is  found  in 
the  shops  bearing  the  names  of  the  parties  in  whose  laboratories  it  is 
prepared.  The  preparations  of  it  in  common  use  are  HaAvley's,  Horlick's, 
Mellin's,  Keasbey  k  Mattison's,  and  the  baby  sup.  As  regards  Keasbey 
&  Mattison's,  Horlick's,  and  Mellin's  Liebig'sfood,  chemical  examination 
shows  that  in  samples  from  the  laboratories  of  these  gentlemen  the  con- 
version of  starch  into  glucose  and  dextrin  is  complete. 

The  following  statements  indicate  the  nature  of  Liebig's  food,  and 
the  w^ay  in  which  it  is  prepared.  Starch  is  transformed  into  sugar  and 
dextrin,  a  change  which,  when  farinaceous  substances  are  used  in  the 
usuiii  way,  is  effected  in  the  system,  and  thus  the  digestive  organs  are 
relieved  from  a  part  of  the  burden  of  digestion. 

"The  following  is  the  best  way  of  preparing  this  food:  Half  an 
ounce  of  wheaten  flour,  and  an  equal  quantity  of  malt  flour,  seven 
grains  and  a  quarter  of  bicarbonate  of  potassium,  and  one  ounce  of 
water,  are  to  be  well  mixed;  five  ounces  of  cow's  milk  are  then  to  be 
added,  and  the  whole  put  on  a  gentle  fire.  When  the  mixture  begins 
to  thicken,  it  is  removed  from  the  fire,  stirnvl  during  five  minutes, 
heated  and  stirred  again,  till  it  becomes  quite  fluid,  and  finally  made  to 
boil.     After  the  separation  of  the  bran  by  a  sieve,  it  is  ready  for  use. 


64  ARTIFICIAL    FEEDING. 

By  boiling  it  for  a  few  minutes,  it  loses  all  taste  of  the  flour."  (London 
Lancet^  January  7,  1865;  Braithwaite  8  Retrospect,  July,  18(55.) 

This  food,  according  to  Liebig,  furnishes  double  the  amount  of  nutri- 
ment contained  in  milk;  or,  as  he  expresses  it,  is  a  "double  concentra- 
tion" of  that  secretion. 

Dr.  Hassell,  in  a  communication  in  reference  to  this  food  to  the  Lon- 
don Lancet  for  July  29,  1865,  says:  "It  appears  to  me  that  the  great 
merit  of  Liebig's  preparation  consists  in  the  use  of  malt  flour  as  a  con- 
stituent of  the  food;  this,  from  the  diastase  contained  in  it,  exercises, 
when  the  fluid  or  soup  is  properly  prepared,  a  most  remarkable  influence 
upon  the  starch,  quickly  transforming  it  into  dextrin  and  sugar,  so  that 
in  the  course  of  a  few  minutes  the  food,  from  beino;  thick  and  sugarless, 
becomes  comparatively  thin  and  sweet." 

Liebig's  food  should  be  used  Avitli  milk,  in  varying  proportions  accord- 
ing to  the  age  of  the  child.  Among  the  many  foods  found  in  the 
shops  besides  Liebig's,  Nestle's  should  be  noticed,  since  it  is  favorably 
mentioned  by  high  authorities  as  Henoch,  and  is  largely  used  Avith  good 
results  in  many  instances.  It  consists,  as  stated  above,  of  wheat  flour, 
yelk  of  egg,  condensed  milk,  and  sugar.  One  thousand  parts  contain 
twenty  parts  of  nitrogenized  matter  and  seven  of  salts.  The  samples 
which  I  have  examined  have  been  alkaline.  Since  it  consists  largely  of 
Swiss  condensed  milk,  no  milk  is  to  be  added  to  it,  and  it  is  quickly 
prepared  by  boiling  it  a  moment  in  nine  or  ten  times  its  quantity  of 
water.  A  list  of  the  foods  Avhich  have  been  found  useful  in  infancy  and 
childhood  would  be  incomplete  without  mention  of  condensed  milk. 

Condensed  milk  is  largely  used  in  the  feeding  of  infants.  The  milk 
is  condensed  in  vacuo  to  one-third  or  one-fifth  its  volume,  heated  to  100°  C. 
(212°  F.)  to  kill  any  fungus  which  it  contains,  and,  when  canned,  38  to 
40  per  cent,  of  cane-sugar  is  added  to  preserve  it.  In  the  first  month 
one  part  of  milk  should  be  added  to  fifteen  of  water,  and  the  proportion 
of  water  should  be  gradually  reduced  as  the  infant  becomes  older.  The 
large  amount  of  sugar  which  condensed  milk,  preserved  in  cans,  con- 
tains, renders  it  unsuitable  in  the  dietetic  role  of  the  summer  diarrhoea  of 
infants.  The  sugar  is  apt  to  produce  acid  fermentation  and  diarrhoea 
in  hot  weather.  Borden's  condensed  milk,  freshly  prepared,  as  dis- 
pensed from  wagons,  contains,  I  am  informed  by  the  agent,  no  cane- 
sugar  or  other  foreign  substance,  and  on  this  account  is  to  be  preferred 
to  that  in  cans.  It  is  cow's  milk  of  good  quality,  from  which  75  to 
79  per  cent,  of  the  water  has  been  removed  under  vacuum.  The 
chief  advantage  which  it  possesses — and  it  is  an  important  one — is  that 
it  resists  fermentation  longer  than  ordinary  milk.  In  not  a  few  in- 
stances which  have  come  to  n)y  notice,  infants  were  found  to  do  better 
when  fed  with  condensed  milk  than  with  ordinary  milk,  or  even  pep- 
tonized milk,  a  fact  readily  explained  by  the  absence  of  fermentation 
in  it. 

The  selection  and  preparation  of  the  farinaceous  food  to  be  used  in 
milk  in  the  feeding  of  infiints  are  important.  It  is  better  for  young 
infants,  as  is  seen  from  facts  stated  above,  that  the  starch,  or  a  pai-t  of 
the  starch  in  their  food,  be  converted  into  glucose  before  the  admix- 
ture.    This  can  be  accomplished  if  a  few  pounds  of  wheat  flour  be  placed 


RULES    FOR    ARTIFICIAL    FEEDIXG.  65 

dry  in  a  muslin  bag,  so  as  to  form  a  ball,  and  boiled  three  or  four 
days  in  water  sufficient  to  cover  it.  The  flour  grated  from  it  has  the  yel- 
lowish color  of  glucose,  and  gives  a  decided  sugar  reaction  to  Fehlino-'s 
test.  A  small  quantity  of  a  good  extract  of  malt,  as  Trommer's  or 
Keid  and  Carnick's,  added  to  a  tepid  gruel  of  any  of  the  farinaceous 
substances,  also  transforms  the  starch,  so  that  it  becomes  thinner  and  is 
probably  more  readily  assimilated  by  the  infantile  digestion;  or  one  of 
the  Liebig's  foods  described  above  may  be  used,  in  Avhicli  the  starch  is 
converted  into  glucose. 

Meigs  and  Pepper,  in  their  standard  treatise,  recommend  for  arti- 
ficially fed  infants  the  admixture  of  prepared  gelatine  or  Russian  isin- 
glass with  the  milk,  and  they  state  that  in  their  practice,  extendinor 
over  many  years,  infants  "have  thriven  better  upon  it  than  upon  any- 
thing else."  A  piece  of  gelatine  two  inches  square  "is  soaked  for  a 
short  time  in  cold  water,  and  then  boiled  in  half  a  pint  of  water  until 
it  dissolves — about  ten  or  fifteen  minutes."  To  this  is  added,  with 
constant  stirring,  the  milk,  containing  some  farinaceous  food.  Others 
who  have  used  food  prepared  in  this  manner  speak  well  of  it.  Although 
gelatine  contains  little  nutriment,  its  presence  may  aid  digestion,  and  a 
food  recommended  by  physicians  of  such  experience  as  Meio^s  and 
Pepper  is  worthy  of  trial  in  cases  of  habitual  indigestion,  or  of  intestinal 
catarrh,  in  which  the  ordinary  food  disagrees. 

Milk  should  be  the  chief  article  of  food  during  infancy,  but  the  older 
the  infant  becomes,  the  larger  should  be  the  proportion  of  solid  food 
given  with  it.  After  the  first  year  the  food  may  be  made  of  such  con- 
sistence as  to  be  given  with  the  spoon.  In  the  second  year  and  subse- 
quently, a  pap  may  be  made  of  stale  bread  boiled  in  water  sufficient  to 
cover  it,  and  mixed  with  fresh  milk,  care  being  taken  that  all  lumps  are 
reduced  to  a  pulp.  Beef  tea  is  a  laxative,  on  account  of  the  salts  which 
it  contains,  as  is  also  chicken  tea;  but  a  small,  or  moderate,  amount  of 
it  may  be  given  once  a  day.  Stale  wheat  bread  or  soda  cracker  should 
be  crumbled  in  it  and  soaked,  so  as  to  be  soft.  If  there  be  diarrhoea, 
the  ordinary  beef  tea  should  not  be  allowed,  on  account  of  its  laxative 
effect,  but  the  expressed  juice  may  be  given  instead.  Few  vegetables 
are  proper  fn*  infants  under  the  age  of  one  year,  but  the  potato,  baked 
and  mashed  so  as  to  Ite  like  flour,  may  be  given  at  the  tenth  or  twelfth 
month.  It  contains  a  large  amount  of  starch,  but  appears  to  be  readily 
digested  by  infants  of  the  age  mentioned,  if  given  once  a  day  in  mod- 
crate  quantity,  with  a  little  butter  and  salt  added.  In  the  second  year 
a  greater  variety  of  food  may  be  allowed,  but  the  full  diet  of  the  tiible 
must  not  be  given  till  after  infancy,  or  at  the  age  of  three  years.  In  the 
beginning  of  the  second  year  the  infant  is  weaned.  He  has  twelve 
teeth,  eight  incisors,  and  four  molars,  which,  with  their  broad  surflices, 
are  designed  for  chewing.  Let  him  have  now,  once  or  twice  each  day, 
in  addition  to  the  food  which  has  previously  been  employed,  a  small 
piece  of  roast  beef,  rare  done  and  cut  very  fine.  Other  meat,  a>< 
mutton,  may  sometimes  be  given  instead.  After  the  age  of  eighteen 
months,  light  puddings  of  farinaceous  substances,  properly  prepared,  as 
of  rice  and  corn  meal,  may  be  added  to  the  dietary. 

All  the  teeth  of  tiic  first  set  have  appeared  at  the  age  of  two  years 

6 


66  BATHING,    CLOTHING,    SLEEP,    EXERCISE. 

and  five  months,  and  the  time  has  now  arrived  when  a  more  marked 
transition  may  be  made  from  liquid  to  solid  food.  Certain  fruits  may 
be  allowed,  even  before  this  period ;  as  also  the  jellies  of  most  berries, 
and  of  fruits,  which  being  deprived  of  seeds  and  parenchyma  arc  for 
the  most  part  readily  digested,  Avhile  they  give  a  relish  to  the  farina- 
ceous food  with  which  tliey  are  eaten.  Pastries  as  ordinarily  made, 
whatever  fruit«  they  may  contain,  are  too  rich  and  indigestible  for 
young  children.  The  following  judicious  rule  for  the  preparation  of 
fruits  for  children,  copied  in  popular  treatises  on  hygiene  of  infancy 
and  childhood,  is  from  iir?(7Ta//'s  Modern  Cookery  Book.  .  ,  .  "Put 
ap])lcs  sliced,  or  plums,  currants,  gooseberries,  etc.,  into  a  stone  jar, 
and  sprinkle  among  them  as  much  Lisbon  sugar  as  necessary  ;  set  the 
jar  in  an  oven  or  on  a  hearth,  Avith  a  teacupful  of  Avater  to  prevent  the 
fruit  from  burning;  or  put  the  jar  into  a  saucepan  of  Avater,  till  its  con- 
tents be  perfectly  done.  Berries  and  fruits  thus  prepared,  and  the  fruit 
jellies,  are  best  eaten  spread  on  bread  and  butter,  or  on  soda  crackers." 


CHAPTER  IX. 

BATHING,  CLOTHING,  SLEEP,  EXEECISE. 

Bathixg  is  noAV  recognized  in  all  civilized  countries  as  one  of  the 
chief  promoters  of  bodily  comfort  and  health.  The  first  bathing  of  the 
infant,  Avhich  is  immediately  after  birth,  should  be  in  Avater  at  a  tem- 
perature a  little  beloAv  that  of  the  blood,  namely,  at  about  96°,  after 
Avhich  the  general  bath  is  inadmissible  until  the  navel  string  is  detached. 
In  the  infant,  reaction  of  the  surface  Avhen  chilled  is  tardy  and  uncer- 
tain, and  therefore  there  is  great  danger  of  catching  cold  Avhen  the 
surface  is  cooled  by  Avater,  and  does  not  quickly  react.  It  is  a  matter 
of  daily  observation  that  infants  become  chilly  and  their  extremities  re- 
main cool  in  a  medium,  Avhether  air  or  Avater,  in  Avhich  older  children 
and  adults  Avould  have  comfortable  Avarmth.  Therefore  they  are  liable 
to  contract  bronchitis,  sore  throat,  intestinal  catarrli,  or  other  inflam- 
mation, from  very  slight  exposures.  This  fact  must  be  borne  in  mind 
in  considering  the  subject  of  bathing. 

During  the  first  year  after  the  detachment  of  the  navel  string,  the 
bath  should  be  employed  daily,  but  not  longer  than  three  minutes ; 
during  Avhich  time  thorough  ablution  can  be  performed.  Different 
authorities  disagree  in  regard  to  the  proper  temperature  of  the  bath 
during  the  fii'st  months  of  infancy.  Steincr  of  Prague,  a  high  authority 
in  children's  diseases,  says,  "  During  the  first  nine  months  the  infant 
should  have  a  daily  bath  a  little  above  blood  heat,"  .  .  .  but  most  state 
a  temperature  a  little  beloAV  blood  heat.     In  my  opinion  it  should  be 


CLOTHIXG.  '  67 

at  92°,  which  is  considerably  below  blood  heat,  but  which  communicates 
a  moderately  warm  sensation  to  the  hand.  After  the  age  of  ten  months, 
or  even  of  eight  months  for  vigorous  children,  the  temperature  of  the 
bath  may  be  reduced  to  90°,  and  it  should  not  be  lower  than  this  dui-ino- 
the  remainder  of  infancy,  or  if  it  be  used  a  little  lower,  care  should  be 
taken  to  produce  reaction  by  brisk  rubbing  and  exercise,  after  a  short 
bath.  At  the  close  of  infancy,  namely  at  two  and  a  half  years,  the 
temperature  may  be  still  farther  reduced,  but  it  should  not,  even  for  the 
most  robust  children  of  eight  or  ten  years,  be  below  78°,  which  is  re- 
corded on  our  thermometers  as  the  temperature  of  summer  heat,  and  is 
about  that  of  our  northern  lakes  durmg  midsummer. 

The  rules  given  in  the  books,  not  to  bathe  or  direct  a  child  to  be  bathed 
immediately  after  eating,  or  after  much  exercise,  when  the  pores  of  the 
skin  are  perspiring,  should  be  heeded.  The  head  should  first  be  wet 
with  the  water,  and  Castile  soap  should  be  applied  over  the  surface  to 
insure  cleanliness.  The  strongly  scented  toilet  soaps  sometimes  contain 
rancid  fats,  or  other  deleterious  substances,  and  should  be  regarded  with 
suspicion.  In  hot  weather  a  daily  bath  is  advisable,  but  in  the  cooler 
months  it  is  sufficient  if  the  child  bathe  twice  or  three  times  in  the  week. 
If,  from  lack  of  conveniences,  or  for  other  reasons,  general  bathing  be 
dispensed  with  and  the  surface  be  washed  from  a  basin  or  bowl,  cooler 
water  may  be  used  than  would  be  proper  for  the  genei'al  bath,  and  a 
longer  time  to  complete  bathing  would  evidently  be  re(iuired.  The  bath- 
room should  be  comfortably  warm,  and  after  the  bath  the  surface  should 
be  briskly  rubbed  with  flannel,  or,  in  case  of  older  children,  with  a 
suitable  coarse  towel,  and  exercise  afterward  encouraged  to  insure  full 
reaction.  In  New  York,  in  one  of  the  largest  and  best  managed  asylums, 
both  boys  and  girls  are  allowed  to  bathe,  in  bath-houses,  in  the  Iludson 
when  the  water  and  Aveather  are  not  too  cool. 

It  may  be  well  to  add  to  these  general  remarks  on  bathing  the  recent 
remarkable  statement  of  a  high  authority  on  thermometric  observations 
and  temperature,  that,  during  hot  days,  a  bath  in  hot  water,  employed 
in  the  hours  of  greatest  atmospheric  heat,  tends  to  reduce  the  heat  of 
body  and  to  preserve  its  normal  temperature  during  the  remainder  of 
the  day.  Wunderlich  says,  "  In  tropical  countries  and  in  very  hot 
seasons,  no  means  of  cooling  is  so  lasting  as  a  bath  or  douche  of  very 
warm  water." 

Clothing. 

One  of  the  most  important  duties  of  the  mother  or  nurse  is  the 
selection  of  clothing  for  children  which  will  be  suitable  for  their  age 
and  the  .season.  In  the  matter  of  dress,  as  in  that  of  diet,  many  errors 
are  unconsciously  committed.  In  a  room  of  proper  temperature,  which 
during  the  cool  months  should  be  70°  for  inffints  and  6<S°  for  children 
old  enough  to  run  about,  the  head  should  never  be  covered  unless  in 
case  of  young  infants;  but  the  sides  of  the  head,  as  well  as  the  neck 
aiul  .shoulders,  may  lie  lightly  covered  in  sleep.  It  is  the  conii!U)n  j)rac- 
tice  to  leave  off  the  ''bellyband"  which  is  ap])lied  after  birth,  when  the 
infant  has  reached  the  age  of  three  or  four  months;  but,  from  the  fact 


68  BATHING,    CLOTHING,    SLEEP,    EXERCISE. 

that  infjints  so  often  take  cold,  especially  at  night  by  throwing  off  bed- 
clothes, both  in  cool  -weather,  when  the  temperature  of  the  apartment 
may  fall  below  70°,  and  in  summer,  when  there  are  currents  of  air 
through  open  Avindows,  I  advise  the  continuance  of  the  band  during  the 
first  year  or  eighteen  months.  In  the  summer  it  should  be  made  of 
light  merino,  and  in  the  winter  of  flannel.  It  should  never  be  so  thick 
and  heavy  as  to  be  uncomfortable,  or  so  snug  as  to  interfere  in  the  least 
with  the  free  movements  of  the  chest  and  abdomen  in  respiration.  It 
should  extend  to  and  not  over  the  ribs,  and  should  be  secured  either 
with  safety  pins  or  a  few  stitches.  If  excoriations  or  prickly  heat 
appear  on  the  skin  under  the  band  in  liot  weather,  a  very  common 
erui)tion  in  infancy,  the  surface  should  be  dusted  with  subnitrate  of 
bismuth,  or  a  mixture  in  equal  parts  of  lycopodium  and  oxide  of  zinc, 
and  a  single  layer  of  linen  should  be  applied  over  it  and  under  the  band. 
If  the  eruption  be  severe,  it  might  be  best  to  substitute  a  linen  or  soft 
muslin  band  for  a  time  in  place  of  the  merino. 

A  cardinal  principle  in  the  clothing  of  children  is  that  the  garments 
should  always  be  so  loose  as  not  to  interfere  in  the  least  with  the  func- 
tional activity  of  organs.  The  fitting  and  putting  on  of  the  dress  is 
left  too  much  to  the  discretion  of  the  nurse,  Avho  is  usually  ignorant  of 
the  important  facts  in  physiology,  and  unwittingly  and  with  the  best 
intentions  injures  her  charge.  I  have  often  interposed  to  loosen  the 
dress  of  young  infants,  which  was  so  tight  as  sensibly  to  embarrass 
respiration;  and  the  case  of  a  new-born  infant  has  been  reported  to  me 
in  Avhich  it  seemed  probable  that  death  resulted  from  this  cause.  Infants 
especially,  who  are  so  liable  to  pulmonary  collapse  and  intestinal  hernia, 
should  have  loose  covering  of  both  chest  and  abdomen.  Pressure  over 
the  stomach  ahvays  feels  uncomfortable,  and  this  organ,  almost  as  much 
as  the  lungs,  needs  full  expansion  and  free  movement,  in  order  to  per- 
form its  function  of  digestion  properly.  The  same  is  true  also  of  the 
intestines,  but  they  tolerate  compression  better,  and  their  movements 
are  less  impeded  than  those  of  the  stomach  by  too  tight  .dressing. 
Another  part,  where  too  snug  an  application  of  the  dress  does  very 
great  harm,  is  the  neck,  since  moderate  pressure  in  this  region  may 
retard  the  circulation  of  blood  through  very  important  vessels,  namely, 
those  which  supply  the  brain,  or  return  blood  from  this  organ.  The 
dress  about  the  neck  should  always  be  so  loose  that  the  four  fingers  of 
the  nurse  can  be  readily  introduced  underneath  it.  Skirts  upon  girls 
are  sometimes  supported  by  being  tied  tightly  around  the  waist  and  over 
the  stomach.  This  shouhl  never  be  allowed,  but  they  should  always  be 
supported  by  shoulder  straps,  and  be  loose  around  the  waist. 

Clothing  protects  the  body  according  to  its  thickness  and  the  feeble- 
ness of  its  conducting  power  of  heat.  Woollen,  fur,  and  feather  gar- 
ments have  very  low  conducting  power,  and  wool,  from  its  plentiful 
supply  and  cheapness,  must  always  be  the  material  which  is  chiefly 
worn  in  the  winter  season ;  while  cotton,  and  in  still  greater  degree 
linen,  are  active  conductors  of  heat,  allowing  its  quick  escape  from  any 
part  of  the  body  wdiicli  it  covers,  and  they  are  therefore  the  proper 
material  for  summer  clotliing. 

The  color  of  a  garment  matters  little  as  regards  the  escape  of  heat 


SLEEP.  69 

from  the  body,  foi'  whatever  its  color  its  surface  next  the  body  is  neces- 
sarily dark  from  the  exclusion  of  light;  but  the  color  is  important  as 
i-cgards  the  absorption  of  heat  from  the  atmosphere  and  the  solar  rays. 
Black  has  the  highest  absorptive  power,  Avhile  white  has  the  least,  and 
the  mixed  colors  have  absorptive  powers  which  are  intermediate.  In 
experiments  made  Avith  shirtings  of  different  colors,  while  white  received 
100°  F.,  black  received  208°  F.  A  light  color  is,  therefore,  the  best  to 
dress  children  in  during  the  hottest  Aveather. 

The  covering  which  is  proper  for  the  head  of  a  child  when  outdoor, 
must  evidently  vary  considerably  in  different  seasons,  and  in  different 
states  of  weather.  Many  a  young  child,  with  scanty  growth  of  hair, 
has  contracte<.l  that  painful  disease,  inflammation  of  the  ear,  followed 
perhaps  by  a  protracted  discharge,  and  more  or  less  impairment  of 
hearing,  in  consequence  of  taking  cold  from  insufficient  covering  of 
head  and  ears  in  inclement  and  changeable  Aveather;  even  leaving  off 
accidentally  a  band  or  tie  to  which  a  child  is  accustomed  Avill  sometimes 
give  it  a  cold. 

In  this  connection,  I  Avish  to  call  attention  to  the  common  and  dan- 
gerous practice  among  the  poor  of  alloAving  children  to  go  bareheaded 
in  the  sun  during  the  season  Avhen  the  atmospheric  heat  is  highest. 
Not  a  summer  passes  in  Avliich  I  do  not  meet  cases  of  inflannnation  of 
the  brain,  Avhich  I  believe  to  be  largely  due  to  exposure  to  the  sun's 
rays.  There  is  no  better  and  safer  covering  for  the  head  of  a  child, 
Avho  is  alloAved  to  go  in  the  open  air  during  the  hot  weather,  than  the 
light,  cool,  and  inexpensive  straAV  hat. 

The  feet  shoidd  always  be  Avarm  and  dry,  the  shoes  Avbrn  in  Avet 
Aveather  being  Avater-proof ;  and  special  care  should  be  taken  in  the 
selection  of  shoes,  that  they  be  pliable  and  loose,  so  as  to  allow  freedom 
of  growth,  Avithout  compression  of  any  part.  If  during  the  period  of 
groAvth  proper  precautions  are  taken  in  this  respect,  the  chiropodist 
would  have  little  to  do  in  subsequent  years.  Corns,  bunions,  and  in- 
growing toenails  originate  from  shoes  hard  and  unyielding,  or  too 
tightly  fitting. 

Sloep. 

The  ncAV-born  infant  requires  from  fifteen  to  eighteen  hours'  sleep 
each  day.  If  it  do  not  have  this,  and  be  Avakeful,  it  is  probably  not 
Avell.  It  sleeps  therefore  most  of  the  time  Avhen  not  awake  for  nursing, 
bathin*:,  and  chaniie  of  clothin<j.  As  it  f^roAvs  older,  a  less  and  less 
amount  of  sleep  is  required.  At  the  age  of  three  years,  about  nine 
hours  of  sleep  are  needed,  and  it  is  better,  for  liealthy  development,  to 
alloAv  children  of  this  age  one  or  tAvo  hours  of  sleep  in  the  middle  of  the 
day.  They  indeed  often  take  it  by  falling  asleep  on  the  sofa,  or  floor, 
or  in  places  Avhcre  they  are  liable  to  take  cold  through  currents  of  air 
and  scant  covering,  if  not  heeded. 

Much  harm  has  been  done  to  childieii  who  were  wakeful  by  nurses, 
and  mothers  too,  Avho  have  given  them  active  and  dangerous  drugs,  as 
laudanum  or  morphine,  under  some  enticing  name  as  soothing  syrup  or 
cordial.     A  Avakeful  and  fr^'tful  child  is  not  Avell.      Its  ailment  may  be 


70  BATHIXG,    CLOTIIIXG,    SLEEP,    EXERCISE, 

trivial  or  grave,  but  it  should  never,  under  such  circumstances,  receive 
from  mother  or  nurse  any  of  those  proprietary  mixtures,  having  seduc- 
tive names,  Avhich  the  shops  contain.  If  it  need  medicine,  it  should  be 
examined  and  prescribed  for  by  the  physician.  It  is  scarcely  necessary 
to  call  attention  to  some  accepted  and  important  facts  regai-ding  the  dor- 
mitory of  children.  A  free  ventilation  is  re(iuired,  either  through  ven- 
tilators or  open  windows,  and  a  sufficient  nuuiber  of  cubic  feet  of  air 
should  be  allowed  for  each  sleeper.  A  small  room  should  not  contain 
more  than  two  children.  Curtains  should  not  as  a  rule  be  employed, 
and  no  open  vessels  of  foul  water  should  stand  in  the  room,  or  anything 
else  which  may  contaminate  the  air.  The  garment  worn  through  the 
day  must  be  entirely  removed  and  hung  up  away  from  the  bed. 

In  the  asylums  of  New  York,  where  from  long  and  abundant  experi- 
ence the  management  of  children  is  systematized,  infants  and  the 
younger  children  are  usually  put  to  bed  between  six  and  seven,  and 
the  older  children  between  seven  and  eight  o'clock  ;  the  last  meal  or 
supper,  as  I  have  stated  elsewhere,  being  light  and  easily  digested. 


Exercise. 

Exercise  is  an  important  hygienic  requirement.  Harm  often  results 
from  modes  of  exercise  wliich  are  not  adapted  to  the  age.  Occasionally 
I  meet  cases  of  permanent  bow-leg,  which  have  manifestly  resulted  from 
attempts  to  make  infants  stand  at  the  age  of  four  or  five  months. 
They  should  never  be  encouraged  to  walk  or  stand  till  about  the  age  of 
one  year,  and  if  they  do  at  the  age  of  nine  or  ten  months  let  it  be  volun- 
tary, and  not  taught  by  standing  them  upon  their  feet.  In  case  of 
infants  with  racliitis,  which  disease  is  common  in  cities,  and  is  char- 
acterized by  a  lack  of  lime-salts  in  the  bones,  and  can  be  detected  by 
great  backAvardness  in  teething,  attempts  to  stand  or  walk  for  any 
length  of  time  should  be  discouraged,  till  by  the  use  of  lime-salts  and 
cod-liver  oil,  and  improvement  of  the  general  health,  the  rachitis  is  cured. 
Much  of  the  permanent  deformity  which  mars  the  beauty  and  sym- 
metry of  adult  life  originates  in  rachitis  and  might  have  been  prevented. 

The  infant  before  he  is  old  enough  to  stand  takes  sufficient  exercise 
in  a  way  that  is  natural  and  harmless.  Let  him  lie  upon  his  back  in 
the  crib,  or  on  the  floor,  Avith  a  blanket  under  his  body  and  pillow  under 
his  head,  and  all  his  clothes  loose,  so  as  not  to  restrain  the  free  move- 
ments of  his  limbs.  A  healthy  infant  seems  to  enjoy  this  attitude, 
moving  all  his  limbs  sufficiently  to  give  them  the  required  exercise,  and 
evincing  his  delight  and  exuberance  of  life  by  utterances  Avliich  are  as 
expressive  as  words. 

In  the  cool  months  of  our  latitude,  infants  should  not  be  taken -out- 
door until  the  age  of  three  month.s,  and  then  only  for  a  brief  time  in 
the  warmest  part  of  the  day;  but  in  the  summer  they  should  begin  to 
receive  outdoor  air  and  exercise  at  the  age  of  one  month.  In  warm 
weather  tlie  liice  should  never  be  covered  by  a  veil  or  otherwise,  and 
air  and  light  should  have  free  access  to  it.  The  rays  of  the  sun,  how- 
ever, from  a  clear  sky,  should  be  excluded   either  by  a  parasol  or  the 


APXCEA    XEOXATI.  71 

shade  of  trees  or  houses,  or  by  the  carriage  in  which  the  infont  is  car- 
ried. In  cold  weather,  or  when  there  is  a  strong  wind,  the  protection 
of  a  veil  is  needed.  Rude  tossing  of  infants,  which  is  common  in 
families,  shoukl  always  be  forbidden.  Its  eftect  on  the  cerebral  circula- 
tion is  likely  to  be  bad,  and  it  involves  risk  of  a  serious  accident.  In 
one  instance  to  my  knowledge,  death  resulted  from  injury  received  in 
this  way. 

Walking,  as  it  is  the  natural,  so  it  is  the  best,  exercise  for  the  older 
infants  and  during  the  period  of  childhood.  It  promotes  digestion 
when  not  carried  to  the  extent  of  fatigue,  and  gives  gentle  exercise  to 
all  the  muscles.  The  baby-carriage  answers  a  useful  purpose,  when 
combined  Avith  walking.  With  the  ordinary  hired  nurse  it  is  safer  for 
the  infant  to  be  taken  out  in  this  vehicle  than  in  the  arms,  for  if  the 
nurse  in  careless  walking  should  trip,  great  harm  might  result.  In  one 
instance  which  came  under  my  notice  convulsions  and  idiocy  were  plainly 
referable  to  the  fall  of  an  infant  from  its  nurse's  arms  upon  its  head. 

The  ordinary  laAvn  sports  of  childhood,  as  croquet  for  both  sexes, 
plaving  ball  or  quoits  for  boys,  which  are  rendered  more  exciting  by  the 
spirit  of  rivalry,  are  also  useful  for  muscular  exercise  and  development, 
while  they  involve  little  danger.  The  swing  aftbrds  a  pleasant  exercise, 
and  with  the  propulsion  required  it  gives  gentle  but  efficient  activity  to 
most  of  the  muscles. 

Many  of  the  gymnastic  exercises  are  too  severe,  involve  too  much 
risk  of  ruptured  tendons,  sprained  joints,  and  even  of  dislocated  or 
broken  limbs. 

Among  all  the  ingenious  inventions  to  provide  sports  and  pastimes 
for  children,  there  are  none  better  tlian  gardening  and  farming,  where 
facilities  will  allow  it,  conjoined  with  the  ordinary  household  duties. 
The  healthy  and  robust  development  of  the  forming  population,  their 
almost  complete  imminiity  from  rachitic  and  scrofulous  ailments,  is  at- 
tributable to  their  outdoor  mode  of  life,  and  the  many  kinds  of  health- 
ful work  which  farm  life  recjuires.  Such  work  is  always  in  the 
highest  degree  beneficial  for  children  old  enough  to  participate  in  it, 
while  it  develops  the  habit  of  productive  industry. 


CIIAPTEK  X. 

DISEASKS  OF  TIIK  NEW-BOEN". 

Apncea  (Asphyxia)  Neonati. 

Ix  the  healthy  infant,  born  under  fa\'orable  circumstances,  the  two 
importiint  functions  of  life,  respiration  and  circulation,  ar(>  established 
within  the  first  minute.  But  it  not  unfrequently  ha])p('ns.  in  conse- 
quence of  some  unfavorable  circumstance,  that  the  heart  and  lungs 


72  DISEASES    OF    THE    XEW-BORN. 

cease  to  act,  and  tlie  infant  at  birth  lies  motionless  as  one  dead.  Some- 
times in  these  cases  an  occasional  pulsation  of  the  heart  can  be  detected 
when  the  fingers  press  under  the  left  ribs,  but  there  is  no  respiration. 
According;  to  the  nature  of  the  cause,  the  surfoce  is  exsanguine  or 
cyanotic  and  livid. 

Causes. — These  arc  various.  The  fault  may  be  partly  in  the  infant, 
from  feebleness  in  its  development ;  but  the  common  causes  are  com- 
pression of  the  cord  during  birth,  from  breech  presentation  or  otherwise, 
and  powerful,  frequent,  and  long-continued  uterine  contractions,  often 
induced  by  ergot,  but  sometimes  occurring  normally,  which  compress 
the  placenta,  and  consequently  obstruct  the  foetal  circulation.  Detach- 
ment of  the  placenta  before  birth,  and  protracted  labor,  from  pelvic 
malformation  or  otherwise,  even  when  there  is  no  unusual  severity  of 
the  pains,  are  occasional  causes. 

TiiEATMENT. — Obviously  the  treatment  must  be  prompt.  Mucus 
should  be  removed  from  the  mouth  and  fauces  with  the  finger,  and, 
except  in  those  cases  in  Avhich  there  has  been  placental  hemorrhage  or 
anffimia  from  other  causes,  as  exhibited  by  pallor  of  the  surface,  a  few 
drops  of  blood  should  be  allowed  to  run  from  the  cut  extremity  of  the 
cord.  The  flow  induced  aids  in  estaljlishing  the  circulation,  and,  in 
the  large  proportion  of  cases,  in  which  there  is  congestion  of  the 
internal  organs,  gives  partial  relief  to  it.  Brisk  rubbing  of  the  body, 
slapping  of  the  buttocks,  blowing  in  the  fiice,  sprinkling  water  upon  it, 
alternately  transferring  the  body  from  a  tub  of  hot  to  cold  Avater,  may 
be  tried  in  quick  succession,  and,  if  there  be  no  signs  of  returning  ani- 
mation, no  time  should  be  lost  in  resorting  to  artificial  respiration. 

The  child  should  be  placed  on  its  side  upon  the  edge  of  a  table,  with 
a  blanket  underneath  it,  and  the  head  in  such  a  position  that  the  epi- 
glottis fills  forward ;  a  towel  or  napkin  should  be  placed  over  its  face, 
having  a  hole  of  sufficient  size  to  blow  through,  corresponding  with  its 
mouth.  The  physician,  compressing  firmly  the  epigastriinn  with  his 
thumb,  blows  a  full  breath  through  the  hole.  A  little  of  the  air,  not- 
withstanding the  compression,  enters  the  stomach;  some  may  escape 
by  the  nostrils,  and  the  rest  enters  the  lungs.  Immediately  the  hand, 
passing  from  the  epigastrium  to  the  thorax,  compresses  it  gently,  though 
with  sufficient  force  to  produce  expiration.  This  should  be  repeated 
six  or  eight  times  per  minute.  The  action  of  the  hcai-t,  previously 
sloAv,  becomes  (piicker  by  the  artificial  respiration.  I  have  been  able 
to  produce  pulsations  by  this  method  when  the  heart  had  ceased  to  beat 
for  a  considerable  time,  and  death,  to  all  appearance,  had  occurred. 
Some  recommend  placing  the  infant  on  the  right  side,  on  account  of  the 
position  of  the  valve  between  the  auricles,  but  I  think  it  is  better  to 
change  it  from  one  side  to  the  other,  in  order  to  ])revcnt  congestions, 
which  are  so  apt  to  occur  when  the  circulation  is  imperfect.  The  cir- 
culation always  commences  sooner  than  respiration.  The  first  respira- 
tions are  mere  gasps — not  more  than  one  or  two  per  minute  in  cases  of 
decided  asphyxia — but  as  they  become  more  frequent,  they  are  also 
deeper. 

Artificial  respiration  should  be  continued  fifteen  or  twenty  minutes 
in  cases  in  which  no  action  of  the  heart  can  be  detected,  by  pressing 


CAPUT    SUCCEDAXEUM.  73 

the  fingers  under  the  ribs,  when,  if  there  be  no  signs  of  returning  ani- 
mation, the  case  is  hopeless.  If  there  be  any  pulsation,  however  feeble, 
we  should  not  cease  in  the  attempt  at  resuscitation.  Some  prefer 
insufflation  through  a  tube  (as  the  segment  of  a  catheter)  introduced 
into  the  larynx,  and  pressure  upon  tlie  thyroid  cartilage  so  as  to  close 
the  pharynx,  instead  of  upon  the  epigastrium.  The  principle  of  treat- 
ment is  similar,  but  the  mode  which  1  have  recommended  above  1  have 
found  successful  beyond  expectation.  Thus,  in  one  case  in  my  practice 
in  which  pulsation  in  the  umbilical  cord  had  ceased  from  ten  to  fifteen 
minutes  before  birth  in  conse(iuence  of  its  prolapse,  I  employed  artificial 
resf)iration  nearly  a  quarter  of  an  hour  before  there  was  any  appreciable 
pulsation,  but  by  perseverance  tlie  circulatory  and  respiratory  functions 
were  fullv  reestablished,  and  the  child  lived  and  was  vigorous.  When 
respiration  commences,  insufflation  may  cease,  but  it  is  proper  to  aid 
the  respiratory  movements  a  little  longer  by  compressing  the  thorax 
after  each  inspiration.  Still,  the  physician  may  be  disappointed  in  the 
result.  In  not  a  small  proportion  of  cases  the  respiration  continues 
gasping,  and  after  a  few  hours,  perhaps  even  a  day,  death  ensues.  I 
have  made  post-mortem  examinations  of  several  infants  who  have  died 
under  such  circumstances,  chiefly  in  the  Nursery  and  Child's  Hospital, 
about  six  from  recollection,  and  have  found  considerable  uniformity  in 
the  appearance  of  the  viscera.  Only  a  small  portion  of  the  lungs, 
sometimes  almost  none  at  all,  was  found  inflated,  even  wlien  the  cries 
had  for  a  time  been  strong,  and  extravasatcd  blood,  usually  in  consider- 
able quantity,  lay  upon  the  surface  of  the  brain,  evidently  having 
escaped  from  the  meningeal  vessels,  which  were  in  a  state  of  extreme 
congestion  in  consequence  of  the  protracted  or  difficult  birth.  Menin- 
geal apojjlexy,  therefore,  seems  to  me  the  chief  cause  of  the  ill-success 
attending  our  efforts  to  save  those  who  are  so  far  resuscitated  as  to  be 
able  to  breathe. 

Keceiitly  Professor  II.  L.  Byrd,  of  Baltimore,  has  recommended  a 
simple  mode  of  resuscitation.  The  physician  places  his  hands  under 
the  middle  portion  of  the  back  of  the  child,  with  their  ulnar  borders  in 
contact,  and  at  right  angles  to  the  spine.  Extending  his  thumbs,  he 
carries  forward  the  two  extremities  of  the  trunk  by  gentle  but  firm 
pressure,  so  that  they  form  with  each  other  an  angle  of  about  45°  in 
the  diaphragmatic  region.  Then  the  angle  is  reversed  by  carrying 
backward  the  shoulders  and  the  nates.  An  assistant  may  aid  by  sup- 
porting the  head.  By  alternating  these  movements.  Professor  Byrd 
has  succeeded  in  effecting  resuscitation  when  other  methods  had  failed, 
and  when  so  much  time  had  elapsed  that  the  case  would  seem  hopeless 
to  most  practiti(niers.  The  name  and  position  of  Dr.  Byrd  counnend 
this  method  to  consideration  and  trial.  (American  Sujiplemeut  of  Ob- 
stet.  Journ.  of  Great  Britain  and  Ireland,  1873.) 

Caput  Succedaneutn — CephalaBmatoma. 

During  tlie  birth  of  the  child,  extravasation  of  blood  not  infrer|uent]y 
occurs  in  the  part  of  the  scalp  which  presents.  This  results  from  Oie 
passive  congestion,  more  or  less  intense  according  to  the  diuation  of 


74  DISEASES    OF    THE    NEW-BORX. 

labor  and  severity  of  the  labor-pains,  which  occurs  in  the  presenting 
parts.  Caput  succedaneum  is  the  term  employed  to  designate  the 
swelling  thus  caused  when  located  upon  the  head.  Its  seat  is  the 
loose  connective  tissue  of  the'  scalp  external  to  the  pericranium.  The 
tumor  is  soft,  painless,  and  usually  located  upon  the  occiput.  It  consists 
]iartly  of  extra vasated  blood,  but  largely  of  scrum  Avhich  has  ti-ansuded 
from  the  congested  vessels  before  that  degree  of  congestion  required  to 
effect  the  transudation  of  the  corpuscles  was  reached.  I  have  repeatedly 
had  an  opportunity  to  examine  this  tumor  in  still-born  infants  brought 
from  the  lying-in  wards  attached  to  the  Nursery  and  Child's  Hospital, 
and  have  found  when  it  was  slight  that  it  consisted  almost  entirely  of 
serum,  but  ordinarily  when  dissected  it  presented  the  appearance  of  a 
bruise,  with  a  large  proportion  of  serum,  the  blood  and  serum  infiltrating 
the  scalp  to  a  greater  or  less  distance  beyond  the  appreciable  limits  of 
the  tumor.  Caput  succedaneum  requires  no  treatment.  As  it  lies  in 
the  loose  connective  tissue  of  the  scalp,  its  liquid  permeates  the  open 
connectiv^e  tissue  in  every  direction,  and  is  ra])idly  absorbed,  while  the 
tumor  disappears.  The  subsidence  of  the  swelling  is  usually  complete 
within  forty-eight  hours. 

Occasionally  blood  is  extravasated  under  the  pericranium,  detaching 
it  from  the  bone.  This  occurs  in  connection  with  caput  succedaneum, 
and  is  observed  Avhen  the  latter  declines.  The  tumor  thus  produced  is 
designated  cephahBmatoma.  It  is  situated  upon  the  occipital  or  ]»arietal 
bone,  near  the  posterior  fontanelle.  Its  base,  corresponding  Avith  the 
denuded  bone,  is  circular  or  oval,  and  it  rarely  crosses  a  suture.  In 
exceptional  instances  two  cephalrematomata  occur,  located  upon  the 
occipital  and  one  parietal  or  upon  both  parietal  bones.  The  liquid, 
being  surrounded  by  the  firmly  attached  pericranium,  does  not  escape 
into  the  surrounding  tissues,  as  occurs  in  caput  succedaneum,  and  is, 
tlierefore,  more  permanent.  The  tumor  flattens  slowly,  and  does  not 
disappear  till  after  several  weeks.  At  the  age  of  six  months  a  slight 
prominence  can  sometimes  be  detected,  indicating  the  seat  of  the  tumor. 
As  the  pericranium  elevated  by  the  blood  does  not  lose  its  vitality,  it 
soon  begins  to  produce  bone,  so  that  after  some  days  a  ring  of  new 
bone  can  be  detected  by  the  finger  surrounding  the  base  of  the  tumor, 
and  on  the  inside  of  the  detached  membrane  a  layer  of  bone  is  pro- 
duced, thin  at  first  and  flexible,  but  gradually  approximating  the  old 
bone,  and  becoming  firmer  as  absorption  occurs. 

Some  time  since,  a  specimen  was  presented  by  me  to  the  New  York 
Pathological  Society,  shoAving  thi&  accident  and  the  mode  of  cure.  The 
child  died  about  two  months  after  birth,  nnd  the  blood  constituting  the 
tumor,  which  had  been  in  great  part  absorbed,  was  completely  incased 
by  the  old  bone  below  and  the  new  thin  formation  above.  The  cavity 
at  length  becomes  obliterated,  and  there  only  remains  some  thickening 
of  that  part  of  the  cranium  which  corresponds  with  the  location  of  the 
tumor. 

Meningocele,  Encephalocele,  Hydrencephalocele. 

This  is  the  amuogue_of  spma,  bifida.  An  opejiijng  exists  at  some 
point  in  the  skull,  through  which  the  meninges,  or  menm^sjwithbrain 


BRAIN    TUMORS. 


7o 


substance,  protrude.  The  deficiency  is  congenital,  and  the  tumor 
exists  at  birth,  or  is  noticed  socin  a^er.  It  is  termed  a  meningocele, 
if  only  meninges  protrude;  an  encephalocele  if  it  contain  . brain  sub- 
staiice  in  addition  to  the  meninges ;  and  a  hydren^cephalocele^  if,  in 
addition  to  the  b^iin  substance,  the  mass  contain  liquid  in  its  interior. 

The  most  frequent,  site  of  these  tumors  is  the  occipjit,  where  the  pro- 
trusion occurs  from  an  opening  in  or  at  the  edge  of  the  occipital  bone. 
The  iiextjmosMTrequent  location  is  the  nasp-frontal  region.  liaxtJ^ 
they  occur  upon  the  temporal,  parietal,  and  basilar  portions  oTThe 
skull.  Oi'dinarily,  the  opening  in  tlie  occipital  bone,  through  which 
the  protrusion  occurs,  is  at  the  niedian  line,  or  near  it,  anterior  or  pos- 
terior to  the  occipital  protuberance.  The  opening,  if  in  the  anterior 
part  of  the  occipital  bone,  may  extend  to  the  fontanelle;  if  in  the  pos- 
terior part,  it  may  extend  .to  the  foramen  magnum.  It  may  connect 
posteriorly  through  the  foramen  magnum  with  the  cleft  of  a  spina  bifida. 
If  the  opening  in  the  occipital  bone  be  large,  the  tumor  is  also  usually 
large.  Prescott  Hewitt  cites  a  case  in  which  it  extended  to  the  loins ; 
but  so  large  a  mass  consists  mostly  of  liquid,  and  is  rare.  An  occipital 
encephalocele  contains  brain  substance  from  the  cerebelbim  or  posterior 
cerebral  lobes,  or  from  both.  If  the  tumor  upon  the  occiput  be  a 
hydrencephalocele,  the  liquid  is  from  the  posterior  cornu  of  a  distended 
lateral  ventricle,  or  from  a  distended  and  dropsical  fourth  ventricle,  and 
it  occupies  the  interior  of  the  tumor,  the  brain  substance  surrounding  it. 


Fig   4. 


If  the  tumor  be  in  the  frontal  j;ggion,  the  protrusion  usually  occurs 
between  the  cdbi'ifoi'n)  jjljLtc  of  the  ethxu'jhl  bone  and  the  frontal  bone, 
and  it  ap])ears  externally  between  \\\o  nasal  and  frontal  bones.  Ex- 
cef)tionaliy,  the  point  of  protrusion  is  betwoenthe  lateral  halves  of  the 
frontal  bone.  The  anterior  lobe  or  lobes  ot  the  cerebrum  protrude  in 
an  encephalocele  in  this  location ;  if  the  tumor  be  a  hydrencei)halocele, 
the  liquid  is  derived  from  the  anterior  corniuc  of  the  lateral  ventricles. 
As  a  rule,  the  frontal  arc  smaller  than  the  occij)ital  tumors,  and  the 


76  DISEASES   (jf   the   XEW-BOKN. 

skin  covering  them  is  more  frequently  red  and  vascular,  so  as  to  present 
the  aj^jpearance  of  vascular  tumors. 

Except  ion  ;dly,  the  protrusion  occurs  from  a  fontanelle,  or  from  the 
line  oToiie  of  the  sutures,  so  that  it  is  seated  upon  the  side  of  the  skull. 
Cases  are  also  on  record  in  which  the  opening  existed  between  the 
ethmoid  and  sphenoid  bones,  through  the  sphenoid,  or  between  the 
sj)henoid  and  its  greater  wing.  Tumors  in  this  location  appear  in  the 
pharynx  or  mouth,  or  enter  an  orbit  displacing  the  eye,  or  protrude 
through  the  spheno-maxillary  fissure.  The  tumor,  wherever  it  occurs, 
is  usually  an  encephalpcele  or  hydrencephalocele,  the  meningocele  being 
rare.  Its  walls  consisto?  ^kin,  durjLJlUvter,  and  arachnoid,  with  in- 
tervening connective  tissue.  If  the  protrusion  be  at  the  base  of  the 
brain,  of  course  the  external  covering  of  skin  is  lacknig.  In  other 
locations  the  skin  constitutes  the  external  coat,  and  it  maybe  tense 
and  scantily  covered  with  hair,  or  red  and  vascular.  The  interior  of 
the  sac  is  lined  by  the  arachnoid  and  dura  mater.  These  tumors, 
whatever  the  exact  character  of  their  interior,  can  be  more  or  less 
reduced  by  compression,  with  a  return  of  a  part  of  their  contents  into 
the  cranial  cavity ;  but  such  compression  usually  produces  cerebral 
symptoms,  as  stupor,  or  fretfulness,  vomiting,  and  strabismus.  The 
following  characteristics  of  the  three  forms  of  these  tumors  aid  in  their 
differential  diagnosis : 

3Ieningocele. — Small  at  first,  and  remaining  either  small  or  of 
moderate  size,  fluctuation  distinct,  ])edunculated,  translucent,  no  pulsa- 
tion, tense  on  forced  expiration,  reducible. 

Encephahcele. — Small,  base  wide,  no  fluctuation,  opaque,  or  some- 
times translucent  at  the  apex,  distinct  pulsation,  enlargement  by  forced 
expiration,  partly  reducible,  cerebral  symptoms  by  compression. 

Hydrencephalocele. — Tumor  usually  large,  often  pendulous,  and  its 
surface  often  lobulated,  pedunculated,  fluctuating;  portions  translucent; 
pulsation  absent  or  rare.  It  is  seldom  affected  by  pressure,  and  tlie 
patient  is  likely  to  be  microcephalic  from  the  escape  of  brain  substance 
external  to  the  cranium. 

These  protrusions  have  been  mistaken  for  various  cysts,  as  cephal- 
jematoma,  serous  and  sebaceous  cysts,  abscesses,  vascular  growths, 
and  polypi.  The  fact  that  such  errors  in  diagnosis  have  been  made  by 
various  surgeons  shows  the  importance  of  a  thorough  and  careful  ex- 
amination before  operative  measures  are  employed. 

Most  patients  with  this  deformity  die  in  a  few  weeks  or  months. 
The  prognosis  depends  on  the  size  of  the  aperture,  and  the  amount  of 
protrusion.  It  is  most  unfavorable  in  hydrencephalocele,  which  is 
usually  attended  by  deficiency  of  brain  within  the  cranium,  sometimes 
to  such  an  extent  that  the  patient  is  microcephalic,  and  early  death  un- 
avoidable. The  hydrencephalic  tumor  is  very  liable  to  grow,  and,  after 
a  time,  rupture,  causing  immediate  death  in  convulsions  or  collapse. 
In  meningocele,  if  the  aperture  be  small,  the  tumor  may  remain  small, 
become  isolated  from  the  cranial  cavity,  and  the  patient  may  live  for 
years.  But  of  the  three  forms  of  the  tumor,  encephalocele  is  regarded 
as  the  most  favorable,  since  it  is  usually  small,  and  patients  with  it 
not  unfrequently  grow  up  to  puberty.     The  prognosis  in  these  tumors 


OPHTHALMIA    XEOXATT.  77 

is  very  similar  to  that  in  spina  bifida,  Avhich  varies  according  to  size  of 
the  aperture  and  the  amount  and  character  of  the  protrusion. 

Treatment. — Those  Avho  have  had  experience  Avith  this  tumor  concur 
for  the  most  part  in  the  opinion  that  surgical  interference  should  not 
be  resorted  to  unless  rupture  be  imminent.  The  rnass  should  be  pro- 
tected from  abrasion,  and  that  degree  of  p^'essure  should  be  employed 
which  can  be  tolerated  without  producing  cerebral  symptoms.  It  is 
proper  to  draw  off  tlie  Ijo^uicLjjf  ca.jn.eningocele,  Jf  it  be  distended  and 
likelyjg  rupture,  and  the  tapping  maybe  repeated,  with  exceptionally 
tEeresult  of  a  cure^or  of  ren(lering  the  tumor  stationary.  jMr.  Holmes 
has  injected  the  tumor  with  two  drachms  of  a  mixture  consisting  of  one 
part  of  tincture  of  iodine  and  two  of  water,  allowing  it  to  remain.  And 
Mr.  Annandale  has  ligatured  the  mass  in  one  instance,  and  effected  a 
cure.  In  encephalocele  and  hydrencephalocele,  support  and  moderate 
pressure  should  be  employied,  and  in  tlie  latter  some  of  the  liquid  should 
be  removed  by  a  small  trocar  if  rupture  be  threatening. 


CHAPTEE    XI. 

OPHTHALMIA  NEOXATI. 

Tins  disease  occurs  in  two  forms,  namely,  the  catarrhal  and  blen- 
norrlujcal,  and  there  are  many  cases  which  are  intermediate. 

Causes. — These  are  not  the  same  in  all  cases.  Exposure  of  the 
infant's  eyes  soon  after  birth  to  a  bright  light,  catching  cold,  tlie  intro- 
duction of  a  little  of  the  vernix  caseosa  under  tlie  eyelids  in  the  first 
washing,  smoke,  dust,  and  irritating  gases,  coming  in  contact  with  the 
eyes,  are  recognized  causes.  Infants  living  in  ill-ventilated  and  dirty 
apartments,  having  untidy  clothing,  with  faces  and  bodies  seldom  pro- 
perly Avashed,  and  attended  by  dirty  nurses,  are  more  frequently  affected 
than  those  in  the  l)ctter  walks  of  life,  and  better  cared  for.  The  disease 
is  more  prevalent  in  asylums  than  in  private  practice,  for  in  the  former 
the  antihygienic  conditions  Avhich  conduce  to  it  more  frequently 
abound. 

Tlie  term  blennorrhocal  is  applied  to  ophthalmia  neonati  when  it  is 
attended  b}'  an  exaggerated  secretion  of  muco-pus.  It  commonly  results 
from  the  introduction  of  a  particle  of  infective  matter  under  tlie  lids, 
during  birth  or  afterwards,  by  careless  handling,  'i'he  gonorrhn-Ml 
virus  may  be  thus  introduced,  or  the  acrid  secretion  of  a  leucorrh(Tca. 
M.  Kroner  states  {Paris  Med.,  February  28,  1885)  "  that  he  found 
the  specific  gonococcus  in  sixty-three  out  of  ninety-two  cases  of  oph- 
thalmia neonatorum."  When  they  were  absent  the  disease  was  less 
severe,  and  not  likely  to  produce  destructive  efiects  upon  the  eye.     He, 


78  OPHTHALMIA    NEONATI. 

therefore,  believes  that  the  classification  of  the  ophthalmia  into  severe 
and  mild  depends  largely  on  the  presence  or  absence  of  the  specific 
gonococcus. 

Symptoms.  Blennorrhoeal  Form. — In  the  beginning  the  palpebral 
conjunctiva  is  observed  to  be  red,  a  little  swollen,  and  its  cutaneous 
surface  presents  a  faint  reddish  tinge.  Light  appears  to  be  painful, 
and  the  child  is  fretful  and  sleeps  but  little;  but  the  eye  itself  has  its 
normal  appearance.  The  progress  of  the  disease,  however,  is  rapid, 
and  in  twenty-four  or  thirty-six  hours  there  is  so  much  tumefaction 
that  the  ujiper  lid  extends  over  the  lower,  and  it  may  be  impossible  to 
separate  them  sufficiently  to  obtain  a  view  of  the  eye.  Tiie  tumefac- 
tion is  due  to  oedematous  infiltration.  The  conjunctiva,  both  palpebral 
and  ocular,  now  presents  a  deep  red  hue,  is  thickened  and  swollen,  and 
numerous  fine  granulations  appear  upon  it;  occasionally  also  flakes  of 
very  delicate  pseudo-membrane  can  be  observed  in  addition.  There  is 
an  abundant  production  of  pus  of  a  creamy  appearance,  sometimes 
tinged  with  blood,  which  oozes  out  Avhen  the  lids  are  separated.  A 
critical  period  has  now  arrived,  one  which  may  involve  tlie  destruction 
of  the  cornea  unless  the  case  be  promptly  and  judiciously  treated. 
Indeed,  the  gravity  of  the  disease  relates  chiefly  to  the  state  of  the 
cornea,  which  up  to  the  present  time,  notwithstanding  the  severity  of 
the  inflammation  and  the  amount  of  surrounding  infiltration,  has  re- 
mained transparent  and  apparently  unaffected.  But  within  another 
twent3'^-four  hours  the  cornea  may  lose  its  polish,  and  grayish,  opaque 
spots  of  softening  appear  upon  it.  Soon  perforation  occurs,  the  aqueous 
humor  escapes,  and  the  iris  falls  forward,  closing  the  aperture  and  pre- 
venting further  loss  of  the  liquids  of  the  eye. 

I  have  observed  destruction  of  the  cornea  and  loss  of  sight  chiefly, 
first,  in  cases  of  true  gonorrhoeal  infection,  in  which  there  is  the  maxi- 
mum amount  of  inflammation  and  tumefaction,  extending  even  over  the 
malar  bone  and  supraorbital  ridge,  with  marked  redness  and  elevation 
of  temperature  of  the  lids;  and.  secondly,  with  a  less  degree  of  inflam- 
mation in  those  who  were  higldy  scrofulous.  Attention,  then,  to  the 
cornea  is  a]l-i)nj)ort;int,  since  it  can  usually  l)e  saved  with  proper  treat- 
ment, although  there  may  so  much  purulent  discharge  and  oedema  that 
it  may  be  impossible  to  see  it  for  several  days.  Occasionally  the  cornea, 
instead  of  sloughing,  becomes  infiltrated  to  a  greater  or  less  extent,  and 
ulcerates,  but  without  perforation.  As  the  patient  recovers,  cicatriza- 
tion occurs. 

The  inflammation  soon  begins  to  decline.  The  swelling,  heat,  and 
redness  of  the  lids  and  conjunctiva,  and  tlie  granulations,  gi'adually 
disappear,  and  recovery  is  complete,  except  so  far  as  the  cornea  may 
have  been  injured. 

Catarrhal  Form. — The  inflammation  is  from  the  first  of  a  mild  grade, 
pertaining  chiefly  to  the  palpebral  conjunctiva,  with  but  a  slight  dis- 
charge of  purulent  matter,  and  with  little  swelling  or  increase  of  heat 
in  the  lids.  Attention  is  directed  to  the  complaint  chiefly  by  the 
secretion  which  collects  in  the  angles  of  the  lids  or  upon  their  border. 
There  may  be  slight  intolerance  of  light,  and' ordinarily  minute  granu- 


OPHTHALMIA    XEOXATI.  79 

lations  appear  upon  the  inflamed  mucous  surface.  This  form  of  the 
disease  may  disappear  within  a  few  days,  or  it  may  be  protracted. 

Ophthalmia  of  the  new-born  is  contagious,  sometimes  highly  so.  It 
commences  on  one  side,  and,  without  precautions,  commonly  within  a 
few  days  extends  to  the  other. 

Treatment. — As  soon  as  the  inflammation  occurs,  the  opposite 
sound  eye  should  be  covered  with  a  compress,  kept  in  place  by  strips 
of  adhesive  plaster.  This  eye  should  be  examined,  however,  once  or 
twice  daily,  in  order  to  detect  the  commencement  of  inflammation,  and 
the  bandage  be  reapplied. 

Catarrhal  ophthalmia  requires  very  simple  treatment.  Frequently 
bathing  the  lids  with  lukewarm  water,  or  milk  and  water,  so  as  to 
remove  the  secretion  from  between  the  lids,  suffices  in  a  large  propor- 
tion of  cases.  In  the  severer  cases,  lead-water  constantly  or  frequently 
applied  to  the  exterior  of  the  lids  is  useful.  Among  the  poor,  mothers 
ordinarily  bathe  the  lids  with  breast-milk,  and  by  this  simple  treatment 
effect  a  cure.  If  the  inflammation  do  not  soon  abate  by  this  treatment, 
a  mild  collyrium  of  one-fourth  grain  of  nitrate  of  silver  to  one  ounce 
of  water  should  be  applied  between  the  lids  and  allowed  to  run  under 
them. 

Blennorrhoeal  ophthalmia,  on  the  other  hand,  requires  prompt  and 
judicious  management.  There  is  scarcely  a  disease  in  which  delay  is 
more  disastrous. 

The  frequent  removing  of  the  pus  is  very  important,  which  confined 
in  large  quantity  underneath  the  closely  compressed  lids,  by  its  pressure 
and  irritation  increases  greatly  the  danger  of  destruction  of  the  cornea. 
Therefore,  the  lids  during  the  height  of  the  inflammation  should  be 
presse<l  apart  every  hour,  so  as  to  allow  the  pus  to  escape,  and  the  space 
between  the  lids  be  freed  from  it  by  a  camel-hair  pencil  or  a  pledget  of 
finely  picked  lint.  Warm  water,  containing  boracic  acid  three  grains 
to  the  ounce,  should  be  gently  thrown  under  the  lids  every  two  hours, 
to  wash  away  |)us  and  flakes  of  pseudo-membrane. 

Medicinal  applications  to  the  inflamed  conjunctiva  should,  in  most 
cases,  be  mild,  but  be  frequently  applied.  I  have  used,  in  the  treat- 
ment of  purulent  ophthalmia,  as  recommended  by  Professor  Gross,  a 
weak  solution  of  corrosive  sublimate  applied  every  three  hours  between 
and  under  the  lids,  the  pus,  so  far  as  practicable,  having  been  first 
removed  by  the  brush  and  syringe.  The  following  is  the  formula,  and 
the  result  has  ordinarily  been  favorable: 

R. — Ilyd.  chlor.  corros.     .         .         .         .         .         .         •     gr  j  ; 

Af|ujc  losaj         .         .         .         .         .         .         .         •       .5'J  i 

A'lua) :5vj. — Misce. 

NoAV  that  bichloride  of  mercury  has  been  fi)und  to  be  the  most  prompt 
and  efficient  germicide  and  antiseptic,  the  indications  for  its  use  in  this 
disease  are  seen  to  rest  on  a  sound  therapeutic  basis.  In  the  proportion 
of  one  part  to  four  thousand  of  warm  water,  which  is  nearly  of  the  same 
strength  as  employed  by  Prof.  Gross,  and  used  every  second  or  third 
hour,  it  soon  diminishes  the  virulence  of  this  form  of  opiithalniia. 

Still  the  beneficial  result  which  I  have  observed  from  this  collyrium. 


80  OPHTHALMIA    XEON  ATI. 

was  no  doubt  largely  clue  to  the  fre(i[uent  removal  of  the  pus,  the  impor- 
tance of  which  cannot,  in  my  opinion,  be  too  strongly  urged.  In  blen- 
norrhocal  ophthalmia,  during  the  active  period  of  the  inflammation,  with 
hot  and  swollen  lids,  linen  in  single  thickness,  or  two  thicknesses, 
squeezed  out  of  ice-water,  or,  better,  removed  from  a  cake  of  ice,  and 
applied  every  five  minutes  when  it  begins  to  Avarm,  aids  materially  in 
subduing  the  inflammation,  every  moment  of  which,  when  the  lids  are 
much  swollen,  involves  danger  to  the  delicate  cornea.  This  measure, 
therefore,  which  requires  diligence  on  the  part  of  the  nurse,  should  be 
insisted  on.  As  long  as  the  cornea  retains  its  transparency  and  polish, 
the  eye  is  safe,  but,  as  stated  above,  it  is  often  difficult  to  obtain  a  view 
of  it  for  some  days. 

The  decline  of  the  inflammation  is  gradual,  but  generally  pretty 
rapid,  yet  several  weeks  may  elapse  before  there  is  full  restoration  to 
the  normal  state.  When  the  inflammation  begins  to  abate,  and  the 
dangerous  tumefiction  has  to  a  great  extent  subsided,  a  collyrium  of 
one-fourth  grain  of  nitrate  of  silver  to  the  ounce  will  expedite  the  cure. 

Occasionally  granulations  remain  upon  the  lids.  If  they  do  not 
diminish  and  disappear  when  the  purulent  inflammation  has  ceased,  I 
Avould  not  practise  excision,  as  recommended  by  Vogel,  but,  having 
everted  the  lids,  apply  a  solution  of  nitrate  of  silver,  five  or  ten  grains 
to  the  ounce,  to  the  granulations,  each  second  day,  and  immediately 
wash  away  the  solution  by  a  camel-hair  pencil  with  salt  and  water,  and 
apply  a  little  sweet  oil  before  the  lid  is  returned.  If  the  granulations 
do  not  disappear  with  this  treatment,  they  may  be  lightly  touched  with 
the  smooth  surface  of  a  crystal  of  sulphate  of  copper,  followed  by  the 
application  of  water  and  sweet  oil.  By  this  mode  of  treatment,  em- 
ployed from  the  commencement  of  the  inflammation,  a  large  proportion 
even  of  the  severest  cases  do  well. 

Doctor  0.  D.  Pomeroy,  oculist,  has  kindly  favored  me  with  the  fol- 
lowincr  remarks  relatino;  to  the  treatment  of  this  disease : 

"The  first  indication  of  treatment  is  thorough  cleanliness.  The  eyes 
should  be  washed  out  with  tepid  water  and  salt — a  drachm  to  the  pint. 
This  may  be  done  every  one,  two,  or  three  hours,  according  to  the 
amount  of  discharge.  The  latter  never  should  be  allowed  to  remain  in 
contact  with  the  cornea  long  at  a  time,  on  account  of  its  excoriating 
effect.  A  soft,  old  linen  rag  or  soft  sponge  may  be  used  to  apply  the 
salt  Avater:  an  assistant  separates  the  lids  and  the  water  is  squeezed  out 
of  the  sponge  into  the  eye.  A  syringe  is  objectionable  on  many  ac- 
counts; one  being  that  the  poisonous  matter  may  be  thrown  against  the 
operator's  eyes.  Frequently  the  discharge  may  roll  into  stringy  masses, 
requiring  them  to  be  wiped  away  by  means  of  the  soft  rag. 

"If  the  attack  be  mild,  I  Avould  be  A^ery  slow  to  order  astringents  or 
stimulants.  Atropine,  one  gi-ain  to  the  ounce,  used  three  or  four  times 
dail}',  must  ahvavs  be  prescribed  in  any  case  Avhatever,  for  the  corneal 
lesions  are  the  only  ones  Ave  fear.  Acid,  carbol.,  two  to  four  grains  to 
the  ounce,  may  be  used  several  times  a  day  Avith  a  vicAV  to  stimulate  the 
conjunctiva  gently  and  destroy  the  poison.  Binding  up  the  sound  eye 
is  not  much  practised  in  infants  ;  it  is  difficult  to  keep  the  dressing  on; 
and  it  does  not  always  protect  the  eye ;  further,  the  second  eye  involved 


OPHTHALMIA    XEOX  ATI.  81 

is  not,  as  a  rule,  as  bad  as  the  first  one.  After  three  or  four  days,  if 
the  discharge  become  very  profuse,  and  the  tissues  have  a  relaxed  look, 
astringents  should  bo  prescribed,  but  they  should  never  increase  the  ir- 
ritation, and  should  decrease  the  discharge.  Arg.  nit.,  gr.  ss  to  the 
ounce,  mav  be  used  from  one  to  four  times  daily.  Aluminii  et  potas. 
sulph.,  gr,  iv  to  the  ounce,  may  be  employed  for  the  same  purpose,  very 
freely.  Zinc,  sulph.,  gr.  j  to  the  ounce,  may  also  be  used  in  a  similar 
manner.  After  a  week  or  ten  days,  if  the  lids  still  remain  swollen,  and 
there  be  a  profuse  discharge,  the  lids  may  then  be  everted  and  stronger 
applications  made.  Arg.  nit.,  five  to  ten  gr.  to  the  ounce,  may  be 
brushed  on  every  second  day ;  carefully  wash  with  salt  and  water  before 
returning  the  lid  to  its  natural  position.  Alum  in  saturated  solution 
may  be  used  in  a  similar  manner,  or  acid,  tan,  gr,  xx  to  the  ounce,  or 
cupri  suljihat.  in  ten  gr,  solutions, 

'•  If  the  remcch/  do  good  to  the  eyes,  continue  ;  if  not,  change  to  some- 
thing else,  and  do  not,  on  any  account,  over-irritate  the  eyes. 

"  Cold  may  he  applied  in  the  earlier  stages  with  the  tense,  red,  and 
swollen  lids,  and  insufficient  discharge,  for  one,  two,  or  three  days, 

''  The  rule  is  to  use  the  cold  sufficiently  to  keep  down  any  excess  of 
inflammatory  action.  This  may  be  known  by  diminished  redness,  heat, 
and  swelling,  and  improvement  in  the  appearance  of  the  discharge. 
Cold  applied  about  half  the  time  is  a  good  rule;  for  instance,  keep  it 
on  from  fifteen  minutes  to  an  hour,  then  leave  it  off  for  the  same  time; 
be  guided  by  the  exigencies  of  each  case.  Scarification  of  either  the 
ocular  or  palpebral  conjunctiva  may  be  performed  if  necessary  in  the 
earlier  stage  if  there  be  much  swelling.  The  source  of  the  injury  to 
the  cornea  is  from  interference  with  its  nutrition  in  consequence  of  com- 
pression and  retarded  circulation  of  the  conjunctival  and  episcleral 
vessels,  caused  by  the  swelling.  In  scarifying  the  ocular  conjunctiva, 
the  incision  should  radiate  from  the  corneal  margin  outward,  and  should 
not  be  deep,  but  enough  to  cause  pretty  free  bleeding.  This  should  be 
encouraged  by  bathing  with  warm  water. 

"  WJwn  the  cornea  is  threatened  with  necrosis  or  sloughing,  we  may 
meet  the  indication  as  fijllows :  the  scarification  already  mentioned 
exerts  a  favorable  influence,  but  if  the  lids  be  much  swollen,  perhaps 
impossible  to  evert,  and  likely  enough  in  a  spasmodic  condition  pressing 
upon  the  cornea,  we  may  perform  a  canthotomy — that  is,  pass  a  stout 
pair  of  scissors  into  the  external  canthus  and  divide  the  commissure  by 
one  resolute  cut  extendin<j  to  the  bone.  Tiie  bleedint;  resultin;:'  is  of 
service,  l)ut  the  power  of  the  orbicularis  to  exert  pressure  on  the  eye- 
ball is  temporarily  broken,  which  is  the  main  indication  for  the  opera- 
tion. The  cornea  should  be  carefully  observed  daily  to  see  that  there 
is  no  haziness  or  commencing  ulcer,  or  even  any  abrasion  of  the  epithe- 
lium, for  the  latter  is  often  the  first  sijrn  of  a  commencinjf  ulcer. 

"  In  case  the  cornea  be  seriously  invf)lved,  especially  if  the  eyeball 
be  too  hard  or  tender  to  the  touch,  and  the  patient  be  sufi'ering  unusual 
pain,  paracentesis  of  the  cornea  should  be  performed.  Unless  the 
operator  be  very  skilful,  a  spring  speculum  should  be  used  and  a 
fixation  forceps  to  keep  the  eye  steady.  Tiie  cornea  should  be  pierced 
near  its  periphery,  and  the  broad  cataract  needle  should  be  passed  into 


82  DISEASES    OF    THE    UMBILICUS. 

the  anterior  chamber  with  its  point  well  turned  forward  to  avoid  the 
lens.  In  this  position  it  should  be  gently  tilted,  so  as  to  make  the 
wound  gape,  when  the  liquid  slowly  escapes ;  hold  in  this  position  until 
most  of  the  fluid  is  evacuated,  then  withdraw  the  needle  slowly  to 
prevent  prolapsus  of  the  iris.  This  operation  may  be  repeated  every 
day  or  two  if  necessary.  In  an  epidemic  of  purulent  ophthalmia  in 
young  children,  at  the  New  York  Foundling  Asylum,  I  at  first  had  a 
few  cases  of  perforated  cornea,  but  being  more  on  my  guard,  I  examined 
subsequent  cases  very  carefully;  when  on  the  first  signs  of  corneal 
trouble  I  performed  paracentesis  and  did  not  afterward  have  a  single 
perforation.  However,  the  most  careful  attention  will  not  always 
prevent  trouble.  One  day  you  may  find  the  patient  doing  Avell,  and  on 
the  next  the  cornea  may  be  perforated.  It  is  well  to  remember  that 
this  is  a  very  fatal  form  of  eye  disease. 

'■'■  Abstraction  of  blood  by  leeches  may  also  be  practised.  As  a  rule, 
however,  this  is  not  very  frequently  em])loyed  in  young  children.  One 
leech  may  be  used  at  about  one  inch  from  the  external  canthus,  but 
frequently  it  should  be  removed  before  wholly  filling,  and  the  resulting 
hemorrhage  may  be  stopped  by  pressure  or  styptics.  Repetition  of  the 
leeching  is  rarely  required;  but  the  leech  may  be  applied  again  in 
twenty-four  hours  if  the  hyperemia  return.  A  membrane  sometimes 
forms  on  the  conjunctiva  of  the  lid  or  globe,  or  botli,  which  may  or  may 
not  be  true  diphtheritic  conjunctivitis.  It  is  an  open  question  where 
membranous  conjunctivitis  ends,  and  diphtheritic  conjunctivitis  begins. 
In  either  event  stimulating  applications  must  be  interdicted,  at  least 
until  the  membrane  becomes  thrown  off.  In  other  respects  the  treat- 
ment is  similar  to  what  has  already  been  laid  down.  In  Europe  diph- 
theritic conjunctivitis  is  very  fatal  to  the  eye.  In  this  country,  for 
some  reason  not  well  known,  it  does  not  seem  to  be  so  fatal,  although 
in  a  bad  case  here  the  eye  is  usually  destroyed.  AVhen  the  eyes  have 
nearly  recovered  from  an  acute  attack,  a  chronic  conjunctivitis  may  re- 
sult, even  passing  into  a  granular  conjunctivitis  or  a  true  trachoma,  when 
stimulating  applications  to  the  lids  may  be  used,  including  atropine 
drops  as  a  collyrium  if  there  should  be  any  photophobia  or  corneal 
trouble.  If  the  child  be  of  good  constitution,  hoAvever,  and  the  gen- 
eral health  be  carefully  j>reserved,  this  latter  sequel  to  the  disease  does 
not  often  occur." 


CHxVPTER  XII. 

DISEASES  OF  THE  UMBILICUS. 

"When  properly  managed,  the  cord  desiccates  and  falls  off  between 
the  third  and  ninth  days.  The  nurse  should  not  be  allowed  to  oil  it, 
which  she  will  sometimes  do  unless  forbidden,  as  this  retards  desicca- 
tion.    If  the  dressing  of  the  cord  be  allowed  to  remain  wet  from  the 


THROMBOSIS    AXD    PHLEBITIS.  83 

arine  or  otherwise,  it  does  not  desiccate,  but  decomposes.  This  is  not 
infrequent  in  poor,  intemperate,  and  slovenly  families.  The  decaying 
cord  is  apt  to  produce  inflammation  of  the  navel.  Some  Southern 
physicians,  prior  to  the  late  war,  attributed  the  prevalence  of  trismus 
neonatorum  among  the  slaves  to  the  lesion  of  the  navel  produced  by  this 
cause. 


Thrombosis  and  Phlebitis  of  the  Umbilical  Vein,  Septicaemia  of 

the  Now-born. 

When  the  cord  is  ligated  at  birth,  a  considerable  part  of  the  blood 
in  the  umbilical  vein  Hows  away  and  enters  the  systemic  circulation, 
but  that  which  remains  forms  small  clots  or  throml^i.  These  clots  con- 
tract and  harden,  becoming  in  time  calcified,  and  remaining  inert  and 
harmless  in  the  system,  or  they  may  soften  and  dissolve.  The  ductus 
arteriosus,  as  I  have  frequently  noticed  at  autopsies,  and  probably 
also  the  ductus  venosus,  are  likewise  occluded  by  fibrinous  plugs  when 
at  birth  they  no  longer  participate  in  the  circulation.  But,  so  far  as 
known,  thrombi  forming  in  these  central  vessels  of  the  fiictal  circulation 
do  no  harm  and  have  no  pathological  significance;  whereas  those  in  the 
umbilical  vein  sometimes  entail  serious  consequences,  and  even  death. 
The  entrance  of  air  into  the  umbilical  vein  from  the  umbilical  fossa, 
carrying  with  it  germs  from  an  infected  atmosphere,  may  afford  ex- 
planation of  the  serious  disease  long  known  under  the  designation  of 
umbilical  plilehitis. 

The  remarks  of  Prof.  Zicijler,  of  TiibintTcn,  on  the  issues  of  throm- 
bosis,  will  aid  to  an  understanding  of  the  nature  of  this  disease.  He 
states  the  fact  that  the  history  and  behavior  of  thrombi  differ  in 
different  instances.  In  some  cases  he  says  that  "the  fibrin  is  trans- 
formed into  a  dense  mass,  which  may  persist  unchanged  for  a  long  time, 
and  ultimately  becomes  calcified.  It  is  thus  that  the  chalky  concretions 
called  phleboliths  are  formed  in  the  veins.  The  very  common  issue  of 
thrombosis  in  softening  is  much  less  favorable.  In  simple  or  red  soften- 
ing the  central  parts  of  the  thrombus  arc  first  of  all  changed  into  a 
grayish  or  reddish  pulp,  consisting  of  broken-down  and  shrunken  red 
corpuscles,  pigment  granules,  and  colorless  granular  detritus.  If  the 
softening  then  extend  to  the  surface  layers,  and  if  the  blood  current  is 
still  flowing  over  the  thrombus,  the  pro<lucts  of  disintegration  may  be 
carried  into  the  general  circulation.  .  .  .  The  result  is  the  formation 
of  emboli.  The  most  unfavorable  issue  of  all  is  the  pnrifonii  or  yellow 
softcninr)  of  the  thrombus.  In  this  case  the  thrombus  is  transformed 
into  a  dirty  or  reddish-yellow,  fetid,  pus-like  cream  or  pulj).  This 
contains  a  multitude  of  pus  corpuscles,  and  a  large  proportion  of  a 
finely  granular  matter,  which  consists  in  part  of  fatty  and  albuminous 
detritus,  and  in  part  of  micrococci.  The  latter  frequently  form  groups 
or  colonies,  and  arc  probably  to  be  regarded  as  the  exciting  cause  of 
the  softening  ))rocess.  Such  ))urifonn  thrombi  act  destructively  on  the 
aurrouiKliug  tissues  and  set  up  iiillamination.  The  intima  of  the  vessel 
becomes  turbid  or  opacpio  ;  and  suppurative  inflannnation  begins  in  the 
tunica  media  and  tunica  adventitia,  extcndinj'  to  the  tissue  enclosing  the 


84  DISEASES    OF    THE    UMBILICUS. 

vessel.  Soon  the  entire  thickness  of  the  vessel-wall  is  infiltrated,  and 
takes  on  a  dirty  yellowish  or  grayish  appearance;  ultimately  the  tissues 
undergo  putrid  degeneration.  If  tlie  puriforni  matters  are  carried  by 
the  blood  current  to  distant  spots,  they  there  ])roduee  necrotic  or  putre- 
factive changes  in  the  tissues,  and  set  up  suppurative  inflammation." 

Puriform  or  yellow  softening  of  the  thrombi  in  the  umbilical  vein, 
occurs  in  those  cases  of  inflammation  of  this  vessel,  which  are  attended 
by  symptoms  indicating  general  septic  poisoning.  This  disease  is  usually 
fatal  in  the  new-born ;  it  has  long  been  known  and  described,  but  its 
pathology  has  been  obscure.  The  concise  and  clear  description  of  the 
yellow  softening  of  thrombi,  quoted  above  from  the  Tubingen  professor, 
enables  us  to  understand  its  nature.  It  will  be  observed  that  he  con- 
siders the  introduction  of  micrococci  into  the  thrombus  as  the  cause 
of  the  destructive  changes  which  follow.  It  Avould  seem  an  easy  matter 
for  micrococci  to  enter  the  umbilical  vein  from  the  umbilical  fossa,  and 
it  is  perhajfs  surprising,  in  view  of  the  perviousness  of  this  vessel,  that 
this  accident  is  not  more  frequent.  Tlie  foHowing  were  examples  of 
inflammation  of  the  umbilical  vein,  and  of  septic  infection,  resulting 
from  the  phlebitis : 

Case  1. — In  May,  1884,  an  infant  died  in  the  New  York  Infant  Asylum, 
having  the  following  history :  It  was  born  after  a  natural  labor,  and  there 
was  no  evidence  of  septic  infection  in  the  mother.  The  cord  dropped  on 
the  seventh  day,  and  the  resident  physician  stated  that  the  umbilicus  ap- 
peared raw,  and  a  slight  oozing  of  purulent  liquid  occurred  from  it,  show- 
iug  its  })erviousness.  My  attention  was  not  called  to  the  infant  until  near 
its  death,  when  I  learned  from  the  nurse  that  it  had  been  very  fretful 
during  the  last  week,  and  recently  the  abdomen  had  IxK-omc  so  distended 
an<l  hard,  that  tlie  physician  of  the  asylum  had  diagnosticated  peritonitis. 
Pressure  upon  the  abdomen  seemed  painful,  and  an  exaniinati<jn  of  other 
parts  gave  a  negative  result.  The  rectal  temperature  at  this  time,  within 
two  days  of  its  death,  was  102.4°;  the  day  before,  it  had  been  lOO.G^. 
Death  occurred  on  the  morning  of  the  fifteenth  day. 

The  autopsy  was  made  twenty-six  hours  after  death,  by  Prof.  W.  H. 
Welch.  Six  ounces  of  turbid  serum  Avere  removed  from  the  abdomen, 
containing  yellowish  flakes  of  fibrin.  In  the  vicinity  of  the  umbilical 
vein,  and  upon  the  under  surface  of  the  liver,  es])ecially  along  its  trans- 
verse fissure,  the  peritoneum  was  covered  by  fibrin  ;  iio  marked  congestion 
of  peritoneum  ;  a  number  of  lymphatic  vessels  filled  with  ])us  could  be 
seen  under  the  peritoneal  covering  of  the  diajihragm,  showing  in  what 
way  septic  infection  extends  along  the  lymphatics.  The  lymphatics  of  the 
diaphraLnn  o])en  upon  the  ])leural  surfiice,  and  it  is  probable,  had  the 
patient  lived  longer,  that  sujipurative  ])leuritis  woidd  also  have  occurred. 
The  umbilical  vein  was  filled  from  the  navel  to  the  transverse  fissure  of 
the  liver  with  a  grayish  softened  detritus,  consisting  of  broken-doAvn 
throndii,  with  a  considerable  proportion  of  pus.  Softened  thnunbi  could 
be  traced  the  entire  length  of  the  umbilical  vein,  the  walls  of  which  were 
infiltrated  and  thickened  from  inflammation.  No  thrombi  were  seen  in 
the  portal  vein  or  vena  cava.  Under  the  endocardial  lining  of  the  heart 
hemorrhagic  points  could  be  seen.  The  pericardial  cavity  contained  more 
than  the  normal  quantity  of  serum,  Avith  a  few  flakes  of  fibrin.  The 
bronchi  contained  l)rr)wnish  nuicus,  and  hemorrhasiic  spots  were  observed 
in  the  ])osterior  portions  of  the  lungs ;  no  evidence  of  pneumonia ;  pan- 


THROMBOSIS    AXD    PHLEBITIS.  85 

creas,  suprarenal  capsules,  ovaries,  and  uterus  normal ;  ecchymotic  spots 
under  the  peritoneal  covering  of  the  kidneys,  and  under  the  mucous  mem- 
brane of  the  caliees. 

It  is  probable  that  in  this  ease  septic  micrococci  played  the  im- 
portant part  in  producing  the  many  lesions,  evidently  of  a  septic  nature, 
which  were  present.  These  organs  entering  the  lymphatics,  and  per- 
haps carried  along  in  the  bloodvessels,  find  lodgement  in  various  parts 
of  the  system,  Avhere  they  produce  inflammatory  or  septic  lesions,  with, 
in  most  instances,  a  fatal  result. 

Case  2. — This  infant  at  birth  weighed  eight  pounds  six  ounces.  It  was 
plump  and  well  developed,  and  the  mother  seemed  healthy.  When  four 
or  five  days  old  it  began  to  be  feverish,  one  day  the  temperature  rising  to 
1U4|'.  The  cord  separated  at  the  usual  time  and  the  umbilicus  seemed 
healthy.  At  the  age  of  two  weeks  an  abscess  ap])eared  upt)n  the  scalp, 
one  upon  the  back,  and  another  upon  the  nates,  indicating  sej)tio  infec- 
ti<jn.  These  abscesses  remained  and  new  ones  appeared  as  long  as  the 
child  lived.  At  the  age  of  four  weeks  orchitis  on  one  side  occurred,  and 
continued  for  three  weeks,  when  it  abated.  When  the  cliild  was  two 
months  old  a  prominence  appeared  half  an  inch  above  the  umbilicus,  and 
when  it  had  continued  about  one  week,  the  resident  physician  punctured 
it,  and  bile  instead  of  ])us  escaj)ed.  The  opening  closed  soon  afterwards, 
and.  subsequently,  a  tliseharge  of  bile  occurred  from  the  unil)ilicus, 
which  continued  until  deatli.  The  infant  gradually  wasted  and  became 
weaker,  and  finally  died  at  the  age  of  eight  months. 

Autopsy,  by  Prof.  Welch.  Infant  much  emaciated;  its  length  twenty 
inches ;  the  remains  of  old  abscesses  upon  the  trunk  and  extremities ; 
an  al)scess  on  the  right  side  of  the  occipital  bone  contained  four 
drachms  of  pus,  underneath  which  the  occipital  bone  was  carious  over  an 
area  of  one  inch  l)y  half  an  inch.  The  dura  mater  below  the  carious 
bone  was  thickened,  but  the  ])ia  mater  was  iiormal.  A  probe  passed 
from  the  umbilicus  into  and  along  the  umbilical  vein.  The  umbilicus 
seemed  normal,  except  a  suiall  cicatri.x  at  its  site  ;  heart  normal  ;  lower  or 
depending  jiortions  of  the  lungs,  the  spleen,  kidneys,  suprarenal  capsules, 
and  blad<ler  jiresented  the  appearance  of  jjassive  congestion;  stomach  and 
intestines  nf»rmal ;  tunica  albuginea  of  the  leit  testicle  thickened.  The 
umbilical  vein  was  dilated  to  about  twice  its  normal  size,  its  walls  were 
infiltrated  and  thickened,  and  it  contained  yellow  thickened  bile.  One 
of  the  branches  of  the  vein  traced  into  the  liver  opened  into  an  al)scess 
about  the  size  of  a  walnut,  and  c<mtaining  thick  i)us.  and  through  this 
abscess  a  communication  had  been  established  between  llie  umbilical 
vein  and  the  bile-ducts.  The  gall-bladder  and  the  liepatic  and  cystic 
duets  c(»ntained  bile  and  appeared  normal;  and  the  liver,  except  for  the 
ab.sce.ss,  presented  the  normal  appearance.  The  abscess  was  in  the  right 
lobe,  near  its  post<'rior  border,  and  it  extended  to  tlu-  superior  surface  of  the 
liver.  The  UMd)ilical  vein  contained  bile,  with  jierliaps  some  bile-stained 
])U8,  but  nn  blood  ;   peritoneum,  brain,  spinal  cord,  and   meninL;cs  nornuil. 

Thrombosis  of  the  umbilical  vein,  when  tlie  thrombi  undergo  putre- 
factive changes,  is,  as  is  seen  by  the  above  cases,  one  of  the  most  severe 
and  fatal  maladies  of  the  new-born.  Disintegrating  ]iarticles  of  fibrin 
loade<l  with  micrococci  may  enter  the  circulation,  and  intercepted  in 
distant  organs  cause  embolisms.     More   disastrous   still   is  the  septic 


86  DISEASES    OF    THE    UMBILICUS. 

infection  of  the  system,  such  as  occurred  in  the  above  cases,  and  which, 
as  a  rule,  ends  in  death. 

Treatment. — Little  can  be  done  to  stay  the  fatal  progress  of  the 
disease  "when  putrefactive  decomposition  of  the  thrombi  has  occurred. 
We  may  endeavor  to  press  from  the  vein  into  the  umbilicus  the  par- 
ticles of  disintegrating  fibrin,  and  perhaps  Ave  can  in  some  instances 
inject  into  the  vein  a  mild  antiseptic  liquid,  as  boracic  acid  in  glycerine. 
But  the  results  of  such  treatment  would  bo  uncertain  and  probably 
futile.  Precautionary  measures,  especially  antiseptic  dressing  of  the 
umbilicus,  as  by  dusting  it  •with  iodoform,  might,  if  generally  practised, 
diminish  the  number  of  these  cases. 


Inflammation  and  Ulceration  of  Umbilicus. 

Inflammation  of  the  lunbilicus  sometimes  occurs  in  the  new-born 
about  the  time  of  the  detachment  of  the  cord,  or  soon  after.  It  probably 
results  from  uncleanliness,  or  carelessness  in  the  management  of  the 
cord,  by  which  irritating  and  decomposing  substances  remain  in  the 
umbilical  fossa.  Sometimes  decomposing  particles  from  the  cord  are  the 
probable  irritant.  This  disease  is  also  most  liable  to  occur  in  cachectic 
infants,  or  those  of  scrofulous  parentage,  whose  general  condition  ren- 
ders them  liable  to  inflammations.  The  umbilicus  becomes  red,  slightly 
swollen,  and  moist  by  a  secretion.  Often  the  inflammation  remains  two 
or  three  days  in  this  mild  form,  receiving  no  treatment  except  from  the 
nurse,  and  disappearing  by  the  use  of  the  dusting  powder,  as  lycopo- 
dium,  which  she  employs.  In  other  instances,  it  extends  over  a  radius 
ot  an  inch  or  even  n)ore,  the  w  alls  of  the  umbilicus  become  swollen  and 
infiltrated,  and  ulceration  succeeds.  The  ulcer  is  circular,  occupying 
the  site  of  the  navel,  and  is  attended  by  a  purulent  discharge.  The 
inflammation  may  noAv  gradually  abate,  and  the  ulcer  heal  with  a 
cicatrix  in  place  of  the  umbilicus.  But  in  other  instances,  especially  if 
there  be  decided  cachexia,  the  ulcer  extends  in  breadth  and  width,  till 
finally,  in  the  worst  cases,  the  peritoneum  becomes  involved,  and  per- 
foration or  peritonitis  occurs,  Avith  death. 

Under  unfavoi'able  hygienic  circumstances  the  blood  of  the  infiint 
being  vitiated,  the  ulcer  may  become  gangrenous,  or  the  inflammation 
may  terminate  dii-ectly  in  mortification,  Avithout  the  formation  of  an 
ulcer.  In  either  case  the  prognosis  is  unfavorable.  If  a  dark  broAvn 
slough  occupy  the  site  of  the  umbilicus,  and  a  scro-sanguineous  discharge 
exude  from  underneath,  the  common  result  is  perforation,  peritonitis, 
and  death  in  from  one  to  tAvo  Aveeks. 

Treatment. — Inflammation  of  the  umbilicus,  if  severe,  and  espe- 
cially if  attended  by  destruction  of  the  tissues  involved,  rapidly  reduces 
the  strength.  In  such  cases  four  or  five  drops  of  brandy  should  be 
administered  every  hour  to  tAvo  hours  in  the  breast-milk. 

In  the  simple  inflammation  the  navel  should  be  bathed  Avith  lukcAvarm 
water  three  or  four  times  daily,  and  the  ointment  of  the  oxide  of  zinc 
be  constantly  applied;  or  if  there  be  little  or  no  discharge,  the  naA'el 
may  be  dusted  Avith    poAvdered  bismuth.     In  case   of  ulceration  the 


UMBILICAL    HEMOREH  AGE.  87 

navel  should  be  gently  washed  three  or  four  times  daily  Avith  lukewarm 
water,  to  which  carbolic  acid  is  added — three  or  four  drops  to  the  ounce ; 
and  if  there  be  much  inflammation,  a  light  poultice  of  pulverized  slip- 
pery elm  should  be  applied  in  the  interval,  or  if  the  inflammation  be 
moderate,  the  balsam  of  Peru.  If  gangrene  supervene,  the  parts 
should  be  frequently  bathed  with  carbolic  acid  water,  and  a  cloth  soaked 
Avith  it  applied  over  them,  or  iodoform  should  be  constantly  applied. 
The  slough  should  be  detached  as  soon  as  it  is  so  far  separated  that  its 
removal  causes  no  hemorrhage,  after  which  the  treatment  for  ulceration 
is  appropriate. 


Umbilical  Granulations  or  Fungus. 

When  the  cord  falls,  granulations  sometimes  sprout  out  from  the  ex- 
posed raw  surface,  and  complete  cicatrization  is  impossible  till  they  are 
removed.  They  form  a  rounded  mass  of  pale  reddish  hue,  at  the 
centre  of  the  umbilical  fossa,  bleeding  Avhen  rubbed,  and  causing  con- 
stant moisture  of  the  umbilicus.  The  largest  which  I  have  seen  had 
perhaps  twice  the  size  of  a  large  pea,  and  the'y  may  be  of  any  smaller 
size. 

Treatment. — By  pressing  upon  the  umbilical  parietes  the  tumor 
rises  from  the  fossa,  so  that  a  silk  ligature  can  be  applied  around  its 
base,  Avhen  the  mass  can  be  readily  moved  Avith  the  scissors.  If  the 
granulations  be  small,  they  may  be  removed  by  the  scissors  Avithout  the 
ligature,  and  hemorrhage  prevented  by  touching  the  surface  Avith  lunar 
caustic. 


CHAPTEK  XIII. 

UMBILICAL   IIEMORKHAGE. 

The  granulations  Avhich  have  been  described  above  occasionally  cause 
considerable  hemorrhage  Avlien  injured.  The  profuse  and  even  fatal 
bemorrliage  Avhich  occurs  at  birth,  or  soon  after,  from  too  loose  a  liga- 
ture of  tlie  umbilical  cord,  or  from  laceration  or  otlicr  injury,  is  so  Avell 
knoAvn,  and  its  cause  so  aj)parent,  that  it  need  only  l>e  alhided  to  in  this 
connection.  Bouchut  details  a  case  in  Avhich  death  occurred  even  be- 
fore birth,  from  this  form  of  hemorrhage.  The  child  Avas  attaclied  to 
the  placenta  by  a  very  short  cord,  Avhicli  prevented  delivery  till  it  parted 
by  the  traction  of  the  forceps.  The  bleeding  from  the  umbilical  vessels 
Avas  so  profuse,  that  the  child  Avas  pallid  and  lifeless  Avhen  born. 

There  is  another  form  of  umbilical  hemonhaiie,  cases  of  Avhich  have 
lieen  from  time  to  time  observed  for  more  than  a  century  (one  of  the 
first  on  record  Avas  reported  in  the   Gentleman  s   Gazette^  April,  1752, 


88  UMBILICAL    HEMORRHAGE. 

by  Mr.  Watts,  a  physician  in  Kent,  England),  but  little  Avas  done  to 
elucidate  its  nature  till  three  American  physicians  made  it  the  subject 
of  careful  study,  and  the  monographs  "svhich  they  have  published  ujion 
it  are  the  best  which  the  literature  of  the  profession  atibrds.  Dr. 
Francis  Minot  read  his  paper,  containing  the  statistics  of  46  cases,  be- 
fore the  Boston  Society  for  Medical  Improvement,  in  April,  1852. 
Prof.  Stephen  Smith  prepared  his  paper,  containing  the  statistics  of  79 
cases,  for  the  New  York  Statistical  Society,  in  1855.  It  was  published 
in  the  Neiv  York  Jour?ud  of  Medicine  for  that  year.  Dr.  J.  Foster 
Jenkins  presented  his  monograph  as  a  report  to  the  United  States 
Medical  Association  in  1858,  and  it  was  published  in  the  Transactions 
of  the  Association  for  that  year.  This  paper  is  very  valuable  on 
account  of  its  statistics,  as  the  writer  succeeded  in  collecting  the  records 
of  178  cases  from  medical  journals,  and  gentlemen  of  the  Association. 
These  three  papers  contain  nearly  all  that  is  known  in  reference  to  this 
disease. 

Sex — Age. — Females  are  less  liable  than  males  to  this  hemorrhage. 
In  Jenkins's  cases,  34^  per  cent,  were  females,  65|  males.  The  fol- 
lowino-  table  gives  the  age  at  which  the  hemorrhage  commenced  in  99 
cases : 

Age.  Nos. 

Under  1  day 5 

Under  2  days  ..........  7 

Under  3     "             6 

Under  4     "              3 

5  to     7     "      (inclusive) 32 

8  to  10     "              "                 ^o 

11  to  15     "              "                 16 

16  to  21     "             "                4 

56     "              .                  1 

U'J 

Ordinarily  the  bleeding  commenced  very  soon  after  detachment  of 
the  cord,  but  in  not  a  few  the  cord  was  still  adherent. 

Causes. — The  common  proximate  cause  is  feeble  coagulability  of  the 
blood.  In  the  normal  state,  when  the  cord  is  ligated,  the  fibrin  of  the 
blood,  which  now  ceases  to  flow  in  the  umbilical  vessels,  forms  coagula 
so  firm  that,  by  the  time  the  cord  is  detached,  hemorrhage  is  impossible. 
But  in  the  majority  of  those  affected  with  this  disease,  the  clots  are  so 
soft  and  loose  that  they  do  not  present  any  effectual  barrier  to  the  pres- 
sure of  blood,  which  therefore  oozes  through  them  or  presses  them  away. 
This  lack  of  coagulability  is  easily  demonstrated,  for  if  a  little  blood,  as 
it  escapes,  be  caught  in  a  vessel,  it  will  be  found  to  remain  licpiid  a  long 
time.  This  dyscrasia,  or  morbid  stnte  of  the  blood,  which  Ave  therefore 
recognize  as  a  chief  cause  of  the  hemorrhage,  docs  not  have  the  same 
origin  in  all  cases.  It  is  sometimes  due  to  inherited  syphilis.  The 
infant  affected  with  it  may  be  plump,  and  appear  well  at  birth,  but  in 
most  instances,  Avhen  the  hemonhage  is  to  occur,  it  is  puny  and 
cachectic,  exhibiting  also  local  manifestations  of  the  disease  or  cachexia 
from  which  it  suffers.  Thus,  in  a  cnse  in  my  practice,  the  inf  mt,  puny, 
and  apparently  born  before  term,  was  observed  to  have  several  blebs  of 


UMBILICAL    HEMORRHAGE.  89 

pemphigus  on  the  first  day,  from  some  of  -which  blood  soon  began  to 
ooze,  but  the  fatal  umbilical  hemorrhage  did  not  commence  till  after 
two  weeks. 

In  about  one-fifth  of  the  cases  ecchymoses  or  petechiiie  have  been 
observed  upon  various  parts  of  the  surfiice,  affording  additional  proof 
of  tlie  general  blood  disease. 

Jaundice  is  another  cause  of  impoverislnnent  of  the  blood  in  the  new- 
born, and  therefore  of  umbilical  hemorrhage.  The  writers  who  have 
collected  records  of  the  hemorrhage,  all  remark  the  frequent  occurrence 
of  the  icteric  hue,  both  before  and  during  the  bleeding.  It  is  not  im- 
probable that,  in  certain  instances,  the  jaundice  is  hiiematogenous,  arising 
from  destruction  of  the  red  corpuscles  and  liberation  of  the  luematin,  a 
not  unusual  result  of  a  profound  dyscrasia,  whether  syphilitic  or  origi- 
nating from  some  other  cause.  But  in  other,  and  probably  most  in- 
stances, the  jaundice  proceeds  from  the  liver,  and  is  the  cause  of  the 
change  in  the  blood.  Thus,  in  five  of  Jenkins's  cases,  there  was  occlu- 
sion of  the  hepatic  or  common  bile-ducts,  and  jaundice,  from  the  presence 
of  biliary  acids  in  the  blood,  causes  diminution  in  the  amount  of  fibrin 
and  red  corpuscles.  In  the  ordinary  form  of  icterus  neonatorum,  the 
cause  of  which  some  suppose  to  exist  in  the  relative  fulness  of  the 
capillaries  and  minute  bile-ducts  in  the  acini  of  the  liver,  destructive 
blood  changes  probably  occur  in  proportion  to  the  degree  and  duration 
of  the  jaundice,  and  hence  the  tendency  to  hemorrhage  observed  in 
some  of  these  cases. 

Poor  health  of  the  mother,  and  impoverishment  of  her  blo(^d  during 
gestation,  whether  from  chronic  disease,  as  tuberculosis,  or  antihygienic 
conditions,  also  cause  impoverishment  and  increase  the  fluidity  of  the 
blood  of  the  child,  and  are  therefore  causes  of  the  hemorrhage.  The 
excessive  use  of  diluent  drinks  or  alkalies  by  the  mother  is  believed  by 
some  to  have  a  similar  effect. 

In  certain  cases  the  hemorrliage  is  due  to  an  inherited  hemorrhagic 
diathesis.  In  nine  of  Jenkins's  cases  the  mothers  were  subject  to  menor- 
rhagia,  and  liable  to  bleed  freely  after  parturition,  and  from  injuries; 
and  seventeen  other  mothers  had  each  lost  more  than  one  infant  from 
umbilical  hemorrhage.  Probably  in  those  cases  in  which  the  hemorrhage 
(••iinmences  before  detachment  of  the  cord,  and  external  to  its  point  of 
insertion,  tlie  hemorrhagic  diathesis  is  the  main  cause  of  tiie  Ihjw. 

Although  the  cause  of  undnlical  hemorrhage  in  the  majority  of  cases 
is  the  vitiated  state  of  the  blood  itself,  observers,  among  others  the  late 
Sir  James  Y.  Simpson,  have  met  ca«es  in  which  the  hemorrhage  was 
referable  to  the  state  of  the  vessels.  In  order  that  tlie  vessels  be 
efl'ectualiy  closed  by  the  fibrinous  coagula,  their  walls  shouhl  have  their 
normal  contractility,  l>ut  this  is  in  great  ))art  lost  by  inlhimmation 
(arteritis  or  phlebitis)  which  sometimes  occurs  in  these  vessels,  as  we 
have  already  seen.  Inflammation,  whether  of  artery  or  vein,  causes 
thickening  and  infiltration  of  its  parietcs,  loss  of  tone  on  the  part  of  the 
filtres  of  which  they  are  composed,  and  therefore  a  patulous  state  of  the 
vessel. 

Symptoms. — Ordinarily  umliilical  hemorrhage  occurs  without  any 
premonition,  but  sometimes  it  is  preceded  by  jaundice.     Jenkin.-5  ascer 


90  DIAGNOSIS    OF    INFANTILE    DISEASES. 

tained  that  jaundice  was  a  prodromic  symptom  in  41  out  of  178  cases, 
and  besides  the  icteric  hue,  constipation,  chiy-colored  stools,  deeply 
tinged  urine,  etc.,  Avere  sometimes  recorded.  Rarely  colicky  pains  and 
vomiting  preceded  the  hemorrhage.  The  blood  may  be  arterial  or 
venous,  or  both.  It  oozes  slowly  or  rapidly,  rarely  escaping  in  a  jet, 
even  when  tliere  is  reason  to  believe  that  it  is  arterial. 

Prognosis. — This  is  unfavorable.  Statistics  show  that  five  in  every 
six  perish.  The  prognosis  is  most  unfavorable  when  jaundice  or  pur- 
pura hemorrhagica  is  present.  Those  are  most  likely  to  recover  who 
have  a  healthy  parentage,  no  obvious  dyscrasia,  and  in  whom  the 
hemorrhage  occurs  late,  and  is  not  profuse.  The  average  duration  of 
the  hemorrhag-e  in  82  fatal  cases  in  Jenkins's  collection  was  three  and  a 
half  days,  the  minimum  being  only  three  hours.  After  the  arrest  of 
the  hemorrhage,  death  may  occur  from  exhaustion  or  the  dyscrasia. 

Treatment. — The  treatment  should  be  both  constitutional  and  local. 
It  is  important,  so  far  as  time  will  permit,  to  treat  the  dyscrasia,  and 
as  the  stools  are  frequently  constipated,  a  laxative  is  often  indicated. 
A  laxative  is  not  only  useful  for  its  effect  on  the  hepatic  circulation,  but 
as  a  derivative.  Both  Smith  and  Jenkins  recommend  calomel  for  this 
purpose.  The  modes  of  treating  the  bleeding  parts  have  been  various. 
Those  most  deserving  of  mention  are  the  following :  injecting  a  styptic 
into  the  open  vessels,  applying  a  styptic  by  compress  or  sponge  to  the 
navel,  covering  the  navel  with  dry  or  wet  plaster  of  Paris,  constant 
pressure  with  the  finger,  which  is  tedious,  but  which  maternal  solicitude 
willingly  provides,  and  lastly,  the  use  of  needles  Avith  ligature.  All  of 
these  methods  have  been  more  or  less  successful  in  arresting  the  hemor- 
rhage, but  the  last  is  most  effectual,  though  painful.  Two  needles  should 
be  passed  through  the  umbilicus  at  right  angles,  and  a  waxed  thread 
Avound  around  each  in  the  form  of  the  figure  8.  In  four  or  five  days 
the  needles  should  be  removed,  and  a  poultice  or  simple  dressing  applied. 


CHAPTEE    XIY. 

DIAGNOSIS  OF  INFANTILE  DISEASES. 

General  Observations. 

Diseases  in  early  life  differ  in  important  particulars  from  those  oc- 
curring in  maturity.  Some  which  are  common  in  the  former  age  are 
unknown  or  are  rare  in  the  latter,  and  those  which  occur  equally  at  all 
ages  often  present  peculiar  symptoms  and  a  peculiar  clinical  history  in 
the  young.  Therefore  physicians  Avho  are  skilful  in  treating  adults, 
may  be  unskilful  in  treating  children.     Excellence  as  a  physician  of 


FEATURES,    ETC.,    IX    DISEASE.  91 

children  can  only  be  achieved  by  special  and  continued  study  of  theii 
ailments. 

Again,  as  regards  the  disease  of  infancy,  in  which  period  there  are  a 
great  amount  of  sickness  and  a  large  mortality,  diagnosis  must  evidently 
be  made  from  the  objective  symptoms;  from  examining  the  features, 
attitude,  utterances,  the  pulse,  respiration,  etc.,  and  inspecting  the 
surfaces,  so  lar  as  they  are  accessible  to  view,  and  the  eliminated  pro- 
ducts. We  lack  for  this  age  the  important  information  which  speech 
affords.  Some  general  remarks,  therefore,  in  reference  to  the  appear- 
ances and  functions  of  the  system  in  early  life,  and  the  changes  which 
they  undergo  in  various  pathological  states,  seem  requisite,  in  order  to 
a  clearer  appreciation  of  the  symptoms,  and  more  ready  diagnosis  of 
individual  diseases. 


Features,  External  Appearance  of  Head,  Tinink,  and  Limbs 

in  Disease. 

In  the  new-born,  as  soon  as  respiration  and  the  new  circulation  are 
established,  the  cutaneous  capillaries  become  distended  Avith  ])lood,  and 
the  skin  presents  a  congested  appearance.  By  the  close  of  the  first 
week  this  external  hyperiemia  begins  to  abate,  and  is  soon  replaced  by 
the  normal  capillary  circulation. 

Icterus  is  common  in  the  first  and  second  Aveeks.  Boucluit  attributes 
it  to  mild  hepatitis.  A  much  more  plausible  view  of  its  causation,  and 
probably  the  correct  one,  is  that  of  Frerichs,  Avho  attributes  it  to  the 
effect  on  the  hepatic  circulation  of  li<Tation  of  the  umbilical  cord.  By 
ligation  the  current  of  blood  throuim  the  umbilical  vein  to  the  liver 

o  .  ^  .  .  .  , 

ceases,  the  amount  of  blood  in  the  hepatic  capillaries,  Avhich  connect 
with  the  branches  of  the  vein,  diminishes,  and  then,  according  to 
Frerichs,  by  the  law  of  diffusion,  diversion  occurs  of  a  part  of  tlie  bile 
from  the  he})atic  cells  into  the  capillaries,  while  the  rest  flows  in  the 
normal  manner  into  the  bile-ducts.  The  degree  of  jaundice  is  pro- 
portionate to  the  amount  of  bile  which  enters  the  circulation.  Icterus 
neonatorum  is  ordinarily  not  a  disease  of  importance.  If  the  general 
health  remain  good,  it  subsides  without  medicine  in  the  course  of  one 
or  two  Avceks,  when  the  circulation  through  the  liver  becomes  equalized 
and  regular. 

The  surface,  or  portions  of  the  surfiice,  of  the  new-born  often  present 
for  a  few  hours  a  livid  color,  due  to  the  mode  of  delivery.  Protracted 
lividity  occurs  from  atelectasis  or  malformation  in  the  heart  or  great 
vessels;  lividity  induced  by  exertion  or  excitement,  while  the  respira- 
tion is  normal,  indicates  malformation  of  tlie  heart  or  vessels  ;  tempo- 
rary lividity  sometimes  occurs  in  severe  acute  diseases,  especially  those 
of  the  respiratory  organ.s;  lividity,  whether  temporary  or  permanent, 
is  a  sign  of  im])crfect  decarbonization  of  the  blood. 

The  cheeks  of  children  are  congested  in  febrile  and  inflammatory  dis- 
eases, except  in  a  cachectic  or  ])rostrated  state  of  the  system.  Transient 
circumscribed  conifcstion  of  the  face,  ears,  or  forehead  constitutes  a 
reliable  si^n  of  cerebral  disease.     Strabismus  occurrinir  in  connection 


92  DIAGNOSIS    OF    INFANTILE    DISEASES. 

Avith  febrile  reaction,  oscillation  of  iris,  ine(i[uality  of  pupils,  and  drooping' 
of  upper  eyelids,  also  denote  cerebral  disease.  The  pupils  are  contracted 
during  sleep  ;  evenly  dilated  in  death. 

Dilatation  of  the  alte  nasi  during  inspiration,  Avith  contraction  of  the 
eyebrows  and  a  countenance  indicative  of  suffering,  attends  severe  in- 
flammation of  the  respiratory  organs.  Absence  of  tears  during  the  act 
of  crying  shows  a  severe  and  probably  fatal  form  of  disease  in  infants 
over  the  age  of  four  months. 

Rapid  wasting  of  the  features,  causing  deep  suborbital  depressions, 
prominence  and  pointedness  of  the  cheek-bones  and  chin,  and  hollow- 
ness  of  the  cheeks,  are  signs  of  severe  diarrho-al  malady  ;  the  most 
striking  examples  of  this  sudden  collapse  of  features  are  afforded  by 
patients  affected  with  cholera  infantum.  In  severe  cases  of  this  disease 
the  physiognomy,  from  a  state  of  fulness  and  health,  presents  in  a  fev^ 
hours  such  a  wasted  and  senile  appearance  that  the  friends  with  diffi- 
culty recognize  the  features  Avitli  which  they  are  familiar.  Muscular 
tonicity  is  also  greatly  impaired  in  this  disease,  that  of  the  orbicular 
muscles  of  the  lips  and  eyelids  to  such  an  extent  that  the  mouth  is 
open  and  the  eyeballs  exposed  during  sleep.  Great  emaciation  occur- 
ring gradually,  is  a  symptom  of  subacute  or  chronic  disease  of  a  grave 
character,  often  of  tuberculosis  or  chronic  entero-colitis. 

Strabismus  sometimes  occurs  in  children  who  have  no  serious  disease. 
It  is  then  due  to  simple  paralysis  of  one  or  more  of  the  motor  muscles 
of  the  eye.  But  Avhen  supervening  upon  other  symptoms  of  a  neuro- 
pathic character,  it  is  a  grave  symptom,  indicating  organic  disease  of 
the  encephalon,  as  effusion,  meningitis,  etc.  A  permanently  downward 
direction  of  the  axes  of  the  eyes,  with  smallncss  of  the  face  and  great 
expansion  of  the  cranium,  is  a  sign  of  congenital  hydrocephalus.  The 
scalp  in  this  disease  is  tense,  bald,  or  sparingly  covered  Avith  hair,  the 
fontanelles  and  sutures  open  and  enlarged,  and  the  cranial  bones  yield 
to  pressure.  Great  expansion  of  the  cranium  above  the  ears,  Avhile  the 
frontal  portion  is  not  enlarged,  or  but  slightly,  denotes  hy})ertrophy  of 
the  brain. 

The  appearance  of  the  general  cutaneous  surface  possesses  much 
greater  diagnostic  value  in  the  diseases  of  infancy  and  cliildhood  than 
in  those  of  adult  life.  The  eruptive  fevers  so  common  in  the  young, 
and  comparatively  rare  in  the  adult,  reveal  themselves  to  us  in  great 
part  by  the  changes  Avhich  they  cause  in  the  appearance  of  the  integu- 
ment. The  peculiar  color  of  the  skin  in  constitutional  syphilis,  here- 
after to  be  described,  and  Avhich  is  more  marked  in  infancy  and  early 
childhood  than  at  any  other  age,  is  a  diagnostic  sign  of  great  value  in 
obscure  cases.  In  the  infant  the  cold  stage  of  intermittent  fever  is 
manifested,  not  by  muscular  tremors,  but  by  lividity,  pallor,  and  the 
goose-skin  appearance  of  the  surface. 

Bulbous  enlargement  of  the  fingers  and  incurvation  of  the  nails  are 
signs  of  cyanosis,  and,  therefore,  of  malformation  at  the  centre  of  the 
circulatory  apparatus,  or  of  tuberculosis,  or  chronic  pulmonary  disease 
attended  by  malnutrition.  Enlargement  of  the  spongy  portions  of 
bones,  causing  prominences,  softness,  and  bending  of  the  bones,  and 
consequent  deformity  of  the  limbs,  patency  of  the  fontanelles,  a  large 


ATTITUDE  —  MOVEMENTS  —  THE    VOICE.  93 

and  square  shape  of  the  head  from  calcareous  deposit  external  to  the 
cranium,  and  delayed  dentition,  are  among  the  signs  of  rachitis. 

In  early  infancy  the  glands  of  the  skin  and  mucous  surfices,  or 
which  connect  by  their  orifices  with  these  surfaces,  are  slightly  de- 
veloped. Therefore,  sensible  perspiration  and  lachrymation  are  rare 
under  the  atje  of  three  months.  A  thick  Meibomian  secretion  of  a 
puriform  appearance  collecting  between  the  eyelids  is  an  unfavorable 
prognostic  sign  ;  it  indicates  a  state  of  great  depression  ;  it  is  observed 
most  frequently  in  cerebral  and  intestinal  maladies  shortly  before  death. 
Passive  congestion  of  the  vessels  of  the  conjunctiva  sometimes  occurs 
under  the  same  circumstances,  due  to  feebleness  of  the  heart's  action, 
and  imperfect  capillary  circulation.  It  indicates  the  near  approach  of 
death. 

Attitude — Movements — The  Voice. 

A  sharp,  piercing  cry,  head  firmly  retracted,  flexure  of  the  limbs 
with  a  degree  of  rigidity,  abduction  of  the  great  toe,  clonic  or  tonic 
spasm  of  the  muscles,  irregular  movements  of  one  or  more  limbs,  with 
consciousness  impaired,  or  with  mental  hallucinations,  are  symptoms  of 
grave  disease  of  the  cerebro-spinal  system.  Irregular  muscular  move- 
ments partly  controlled  by  the  will,  and  occurring  during  full  conscious- 
ness, are  symptoms  of  chorea,  a  disease  nearly  always  ending  favorably 
in  children,  though  incurable  in  the  adult.  Contraction  of  the  eye- 
brows, turning  of  the  eyes  and  face  from  light,  avoidance  of  noises,  as 
if  ])ainful,  are  signs  of  headache.  Frequent  carrying  of  the  hand  to 
the  ear,  and  pressing  with  the  ear  against  the  breast  of  the  mother  or 
nurse,  are  symptoms  of  otalgia.  Frequent  carrying  of  the  fingers  to 
the  mouth  in  connection  with  fretfulness  or  other  symptoms  of  suffering, 
indicates  stomatitis,  gingivitis  whether  from  difficidt  dentition  or  other 
causes,  painful  pharyngitis,  or  some  obstructive  disease  of  the  larynx. 
Frequent  rubbing  or  pressing  the  nose  may  be  due  to  intestinal  Avorms 
or  intestinal  irritation  from  other  causes.  It  may  be  due  to  coryza  or 
headache.  Frequent  forcible  rubbing  or  striking  the  nose  should  lead 
to  a  careful  examination  and  perhaps  guarded  jirognosis.  It  often  in- 
dicates grave  cerebral  disease,  and  may  be  a  precui'sor  of  convulsions. 

In  severe  obstructive  disease  of  the  larynx  the  child  is  restless, 
moving  from  side  to  side.  In  most  inflammations  of  the  respiratory 
organs,  a  semi-erect  position  gives  most  relief.  The  voice  in  severe 
laryngitis  is  often  hoarse  or  indistinct,  and  is  usually  so  in  the  pseudo- 
membranous form ;  in  pleuritis  or  pneumonitis  it  is  restrained  and 
aljrupt,  since  the  movements  of  the  walls  of  the  chest  give  pain. 

The  voice  in  severe  diseases  of  the  abdominal  organs  is  feeble  and 
]ilaintivc.  It  is  sometimes  short  and  restrained  in  acute  dysjiepsia,  in 
peritonitis,  and  in  cases  of  great  abdominal  distention.  The  horizontal 
position  gives  most  relief  in  abdominal  diseases.  In  case  of  abdominal 
pain  the  patient  often  prcss-es  his  hand  upon  the  abdomen  and  ilexes 
liis  thigh  over  it.  Perfect  quietude,  with  features  sunken,  and  un- 
changed by  smile  or  crying,  is  a  symptom  of  severe  and  rxhausting 
diarrliueal  aftections. 


94  DIAGNOSIS    OF    INFANTILE    DISEASES. 


Respiratory  System. 

The  respiration  of  the  infant  under  the  age  of  six  months  is  ver^ 
irreguUir,  and  it  is  more  irregular  tlie  nearer  the  time  to  birth.  If  the 
new-born  inflmt  be  closely  observed,  it  will  be  seen  to  sigh  often ;  it 
breathes  pretty  uniformly  and  regularly  for  a  moment,  and  then,  -with- 
out appreciable  cause,  the  respiration  is  intermitted;  it  holds  its  breath 
when  it  smiles  or  moves  its  head,  or  even  its  limbs;  it  is  very  subject 
to  hiccup;  this  is  more  common  the  first  Aveek  of  life  than  at  any  other 
age.  So  much  is  the  breathing  of  the  young  infant  disturbed  by  these 
causes,  that  the  number  of  respirations  ordinarily  varies  in  consecutive 
minutes.  In  order,  therefore,  to  determine  Avith  accuracy  the  frequency 
of  the  normal  respiration  for  this  time  of  life,  it  is  necessary  to  take  the 
average  of  several  observations. 

At  birth,  Avhile  the  function  of  the  heart  has  for  months  been  re^u- 
larly  performed,  the  lungs  are  still  quiescent.  The  one  organ  has  been 
active  during  the  greater  part  of  foetal  development,  the  other  is  yet 
untried.  Hereafter,  in  the  ncAV  order  of  things,  so  intimate  is  the  re- 
lation betAveen  the  heart  and  lungs,  that  the  proper  performance  of  the 
function  of  the  one  is  essential  to  that  of  the  other.  Therefore,  the 
commencement  of  respiration  and  the  return  of  circulation,  which  is 
modified  and  temporarily  arrested  at  birth,  are  nearly  simultaneous. 
Respiration  begins  in  the  first  half-minute  of  independent  existence; 
often,  indeed,  attempts  to  inspire  occur  before  delivery  is  completed. 
The  exceptions  to  this  early  establishment  of  respiration  are  after 
tedious  or  unnatural  births.  The  establishment  of  the  neAV  circulation 
is  a  moment  later. 

Respiration  in  Health. — As  the  air-cells  at. birth  are  closed,  the 
establishment  of  respiration  is  difficult.  The  air  at  first  penetrates  a 
feAV  pulmonary  cells,  but  gradually  more  and  more  are  inflated  through 
the  forcible  inspirations  Avhich  the  crying  of  the  infant  produces,  till 
after  a  variable  time,  respiration  becomes  easy  and  complete.  If  the 
cry  be  feeble,  and  especially  if  AAath  this  feebleness  there  be  considerable 
congestion  of  the  brain,  the  result  of  tedious  birth,  the  full  establishment 
of  respiration  is  in  a  corresponding  degree  gradual  and  slow. 

The  frequency  of  the  respiration  in  health  should  be  ascertained,  in 
order  to  deteiinine  Avhether,  in  a  given  case,  it  be  abnormally  acceler- 
ated. The  folloAving  table  embodies  the  result  of  observations  Avliich  I 
have  made,  in  order  to  determine  the  normal  frequency  of  respiration 
in  the  first  year  of  life. 


RESPIRATORY    SYSTEM. 


95 


Normal  Infantile  Respiration  [number  per  minute). 


Age. 

From  first 

From  close 

From  close 

Close  of 

Close  of 

I 

half  hour  to 

of  first  week 

of  first 

third  to  close 

sixth  month 

close  ot 

first 

to  close  of 

month  to 

of  sixth 

to  close  of 

First 

week. 

first  month. 

close  of  third 

month. 

first  year. 

half 
hour. 

< 

6 

1 
< 

1 
< 

Awake. 

Asleep 

< 

< 

< 

< 

Xiiniber  of  obsenations 

1     29 

28 

14 

V, 

V, 

IG 

10 

25 

7 

in 

0 

Extreme   number  of  res 
pirations  per  minute 

1  25-104 
I     48.5 

32-04 

iO-G4 

40-'JG 

28-00 

32-08 

28-52 

30-88 

24-40 

28-04 

24-36 

Mean  number  of  respira 
tious  per  minute 

.52     \ 

52 

50 

45 

51 

39 

54 

33 

41 

29 

As  the  child  advances  from  the  age  of  one  year,  the  number  of  respi- 
rations per  minute  gradually  diminishes;  but  through  the  ^vhole  period 
of  childhood  it  remains  greater  than  in  the  aJult.  At  the  age  of  five 
years,  Avhen  the  child  is  quiet,  but  awake,  it  is  about  27 ;  at  the  a<re  of 
ten  years,  about  22. 

Respiration  ix  Disease. — In  cerebral  diseases  the  respiration 
becomes  slow,  and  if  somnolence  occur,  intermittent,  and  accompanied 
by  sighing.  In  young  infants,  in  the  drowsiness  which  supervenes 
when  the  blood  is  imperfectly  decarbonized,  during  severe  attacks  of 
capillary  bronchitis,  or  broncho-pneumonia,  respiration  is  likelv  to  be 
intermittent. 

In  inflammatory  diseases  of  the  larynx  and  trachea,  respiration  is 
but  slightly  accelerated,  and,  if  there  be  no  obstruction,  its  rhythm  is 
normal;  if  there  be  obstructive  disease,  its  rhythm  is  altered;  the  inspi- 
ratory act  is  lengthened.  In  bronchitis,  respiration  is  accelerated  in 
proportion  to  the  degree  of  extension  downward  of  tlie  inflammation. 
It  is  in  no  disease  more  accelerated  than  in  severe  capillary  bronchitis. 

In  pleuritis  and  pneumonitis,  the  respiration  is  accelerated  in  pro- 
portion to  the  extent  and  acuteness  of  the  inllammation.  Inspiration 
ending  abruptly,  and  succeeded  by  an  expiratory  moan,  is  a  symptom 
of  both  pleuritis  and  pneumonitis  in  their  acute  stages.  In  certain 
cases  of  irritative  or  inflammatory  disease  of  the  alxlominal  organs, 
respiration  presents  a  similar  character;  it  is  modified  in  this  manner  in 
consequence  of  the  pain  experienced  in  movements  of  the  diaphragm. 
Ordinarily,  however,  in  abdominal  diseases,  resj)iration  is  nearly  natural. 

The  cough  is  an  important  diagnostic  symptom.  It  is  loud  and 
sonorous  in  spasmodic  croup,  hoarse  or  liarsii  in  true  -croup,  clear  and 
distinct  in  bronchitis,  suppressed  and  painful  in  tlie  early  stages  of 
pneumonitis  and  pleuritis,  convulsive  and  with  more  inspirations  than 
expirations  in  pertussis.  A  cough  due  to  coexisting  bronchitis  is  one 
of  the  first  and  most  constant  symptoms  of  measles.  Tyi)hoid  and 
remittent  fevers,  difficult  dentition,  intestinal  worms,  irritating  ingesta, 
and  severe  burns,  sometimes  give  rise  to  a  cough,  which  is  nearly  dry 


96  DIAGNOSIS    OF    INFANTILE    DISEASES. 

and  painless.  Occurring  in  such  diseases,  it  is  sometimes  dependent  on 
more  or  less  bronchitis,  to  which  the  primary  disease  has  given  rise. 

A  strongly  marked  nasal  or  palatal  cry  is  present  in  syphilitic  oznena, 
hvportrophied  tonsils,  and  paralysis  of  the  soft  palate.  If  these  can  be 
excluded,  it  indicates  retropharyngeal  abscess.  On  one  occasion  Pol- 
litzer  heard  this  cry  in  a  bal)y  that  the  mother  said  was  Avell ;  but  he 
introduced  his  finger  in  the  fauces,  felt  the  expected  swelling,  and,  by 
an  incision,  evacuated  a  considerable  amount  of  pus. 

An  excessively  prolonged,  loud-toned  expiration,  with  normal  inspi- 
ration, and  without  dyspnoea,  is,  according  to  Pollitzer,  an  early  symp- 
tom of  chorea,  sometimes  preceding  all  other  symptoms.  He  Avas  once 
called  to  a  child,  apparently  well  and  asleep,  in  whom  this  symptom  had 
continued  two  hours,  and  Avas  supposed  by  the  mother  to  indicate  croup. 
Later  the  ordinary  symptoms  of  chorea  appeared.  The  same  author 
retrards  a  high  thoracic,  continued  sighing  inspiration  as  almost  pathog- 
nomonic of  weak  heart,  and  of  certain  cases  of  acute,  fatty  heart.  Un- 
like the  condition  in  laryngeal  stenosis,  while  the  diaphragm  is  nearly 
inactive,  the  accessory  muscles  of  inspiration  act  strongly.  This  symp- 
tom occurs  early,  before  the  lividity  or  pallor,  or  weak  pulse,  or  cold 
extremities. 

A  disftinct  pause  after  each  expiration,  ascertained  in  a  quiet  room 
by  placing  the  ear  close  to  the  mouth,  distinguishes  laryngeal  catarrh 
from  croup.  (Pollitzer.)  Stridulous  inspiration  usually  indicates  acute 
larvngeal  catarrh,  but  I  have,  in  a  considerable  number  of  instances, 
be^n  asked  to  prescribe  for  infants  with  stridulous  respiration,  Avhich 
commenced  early,  perhaps  in  the  first  or  second  month,  and  continued 
nigbt  and  day  till  about  the  close  of  the  first  year,  Avhen,  in  the  develop- 
ment of  the  cliild,  it  ceased.  It  is  attended  by  no  dyspnoea  or  suffering, 
does  not  interfere  with  the  nuti'ition  or  growth,  is  not  benefited  by  any 
known  treatment ;  and  it  seems  tliat  it  may  exist  within  physiological 
limits. 

A  shrill,  loud  cry,  night  after  night,  in  sleep,  while  the  child  is  well 
in  the  daytime,  is  probably  due  to  dreams,  and  it  may  be  treated  by  a 
large  dose  of  quinine  at  bedtime,  but  a  full  dose  of  the  bromide  of 
potassium  or  sodium  is,  perhaps,  more  apt  to  give  relief.  A  cry, 
lasting  five  or  ten  minutes,  and  occurring  several  times  in  the  day,  indi- 
cates spasm  of  the  bladder,  especially  if  dysuria  be  present.  It  is  best 
treated  by  belladonna,  provided  that  there  be  no  calculus.  A  cry,  during 
defecation,  indicates  fissure  of  the  anus,  and  is  to  be  treated  by  an 
ointment  of  zinc  and  belladonna.  A  violent  and  protracted  cry,  with 
restlessness,  pressing  the  head  on  the  pillows  or  breast  of  the  nurse,  and 
frequent  carrying  of  the  finger  to  the  ear,  indicate  otalgia. 


Circulatory  System. 

In  all  ages  and  countries  the  pulse  has  been  considered  an  important 
symptom,  both  in  diagnosis  and  prognosis.  It  aids  the  practitioner  in 
determining,  approximately,  not  only  the  character  but  the  gravity  of 
diseases.     It  is  somewhat  remarkable,  from   the  importance  which  is 


CIRCULATORY    SYSTEM 


97 


attached  to  the  pulse  in  medical  practice,  that  its  natural  frequency  and 
its  character  in  infancy  are  not  more  accurately  known.  It  is  true  that 
eminent  observers,  as  Trousseau  and  Yalleix,  have  published  statistics 
relating  to  the  infantile  pulse  in  health,  but  these  statistics  disagree,  and 
therefoi'e  do  not  afford  a  reliable  standard  with  which  to  compare  the 
pulse  in  disease.  Moreover,  some  published  statistics  of  the  pulse  pos- 
sess but  little  value,  from  the  small  number  of  observations  ;  some  from 
the  fact  that  records  of  the  infintile  pulse  are  grouped  with  those  of 
older  children  ;  and  others  because  the  state  of  the  infant,  as  reo-ards  its 
activity  or  emotions,  is  not  mentioned. 

Pulse  ix  Health. — It  is  not  easy  to  collect  statistics  of  the  pulse 
during  the  period  of  infancy,  which  are  entirely  free  from  error,  since 
often  slight  derangements  of  the  system  in  the  infant  frerpiently  occur, 
which  are  not  manifested  by  any  marked  symptoms,  but  which  produce 
acceleration  of  pulse.  In  collecting  the  following  statistics,  sources  of 
error,  so  far  as  possible,  were  avoided. 

The  movements  of  the  heart  commonly  begin  about  one-eighth  of  a 
minute  after  birth.  They  are  at  first  slow,  the  ventricular  contractions 
not  numbering  more  than  eight  or  ten  by  the  elose  of  the  first  quarter 
minute.  In  the  second  quarter  the  cries  are  vigorous,  and  the  pulse 
now  is  rapidly  accelerated,  rising  commonly  above  120,  and  sometimes 
above  160  beats  per  minute.  In  fifty-seven  observations  of  the  pulse 
in  healthy  infants  during  the  first  half  hour  of  life,  after  the  first 
quarter  of  a  minute,  I  found  that  the  extremes,  with  one  exception,  were 
104  and  164— average,  139. 


Table  of  Infantile  Pulse  in  Health. 


Age. 

From  close  of 

From  close  of 

From  close  of 

From  close  of 

First  week. 

fii-st  week  to 

first  month  to 

third  month  to 

sixth  month  to 

close  of  first 

close  of 

close  of 

close  of  fiiTit 

month. 

third. 

sixth. 

year. 

Awake. 

Awake. 

Awake 

Awake. 

Awake. 

Quiet  ; 

a. 

Quiet ; 

a. 

Quiet  ; 

a. 

Quiet ; 

a. 

Quiet  ; 

a. 

moving 

moving 

3 

moving 

:i 

moving 

s 

moving 

t 

sli-litly  ; 

•< 

8li?htly; 

< 

sliRhtly  : 

< 

slightly  ; 

<; 

slightly  ; 

< 

nui-sing 

nursing. 

nursing 

nursing 

nursing. 
20 

No.  of  ol> ) 
serviitiiiiisj 

22 

16 

10 

10 

15 

17 

25 

6 

3 

Extruiiics  . 

104-152 

108-140 

124-160 

lOt-144 

112-148  !  104-132 

112-146 

104-116 

112-144 

Mean 

120 

122 

13a 

118 

132      1      118 

129 

108 

127 

109 

"  M.  Lcdeberdcr,"  says  Bouchut,  "could  only  count  the  pulse  in  the 
first  minute  of  life  in  six  children,  and  he  has  observed  from  72  to  94 
pulsations."  Valleix  estimates  the  pulse,  between  the  ages  of  two  and 
twenty-one  days,  at  87.  Trousseau  states  that  the  puJse,  in  the  first 
week  of  life,  varies  from  78  to  150;  and  Dr.  Gorham's  observations  are 
in  the  main  similar  to  Trousseau's.  My  observations,  as  seen  from  the 
above  ta])le,  do  not  correspond  with  the  assertions  of  Ledeberder  and 
Vallei.x.      Imleed,  if  there  were  no  conflicting  testimony,  there  would 


98 


DIAGNOSIS    OF    INFANTILE    DISEASES. 


still  be  a  strong  presumption  tliat  these  authors  are  in  error,  for  we 
would  not  suppose  that  the  pulse  of  the  infant,  in  whom  there  is  greater 
functional  activity,  both  muscular  and  visceral,  would  fall  so  much  be- 
loAV  that  of  the  foetus.  It  is  probable,  from  the  expression,  "  could  only 
count  the  pulse in  six  children,"  that  Ledebcrder,  and  per- 
haps Valleix,  countcvi  the  pulse  in  the  wrist,  which,  with  exceptional 
cases,  is  very  difficult  and  often  impossible  in  the  first  week  of  life,  and 
that  they  missed  some  of  the  beats,  or,  not  unlikely,  sometimes  counted 
their  own  pulse.  Immediately  after  birth  there  is  so  little  force  of  the 
ventricular  systole,  and  the  extreme  arteries,  therefore,  of  the  system 
pulsate  so  feebly,  that  neither  in  the  limbs  nor  at  the  anterior  fontanelle 
can  tlie  fi'oquency  of  the  pulse  be  readily  ascertained.  It  can  be  rcadilv 
and  accurately  ascertained  only  by  auscultation,  or  by  placing  the  hand 
on  the  precordial  region,  or  directly  after  birth  by  the  pulsations  in  the 
umbilical  cord. 

The  average  pulse  of  the  healthy  infant  in  the  first  and  second  months 
is,  according  to  Trousseau,  137  per  minute,  128  from  the  third  to  the 
sixth  month,  and  120  from  the  sixth  to  the  twelfth  month.  It  is  seen 
tliat  his  observations  agree  closely  with  mine,  as  regards  infants  who 
are  quiet,  but  awake.  One  point  of  interest,  established  by  the  above 
statistics,  is  the  great  diminution  in  the  frequency  of  the  pulse  in  sleeji. 

Pulse  during  or  after  Active  Movements  or  Great  Mejital  Excitement. 


Age. 

Close  of  first 

Close  of  first 

Close  of  tliinl 

Close  of  sixth 

First  wec-k. 

w  uck  to  close  to 

to  close  of  third 

to  close  of  sixth 

month  to  close 

first  month. 

month. 

mouth. 

of  fii-styear. 

140 

162 

176 

1.32 

132 

160 

156 

152 

148 

144 

140 

140 

158 

148 

152 

152 

152 

144 

144 

182 

152 

1,56 

198 

180 

156 

160 

Extremes  . 

140-160 

146-162 

144-180 

132-156 

132-198  • 

Mean 

148 

152 

160 

147 

1.56 

It  is  seen,  by  the  above  table,  that  by  active  exercise,  or  great  mental 
excitement,  the  pulse  may  become  as  rapid  as  in  grave  diseases.  There 
is  greater  acceleration  of  pulse  from  the  emotions  and  from  exercise  in 
feeble  than  in  robust  children.  Obviously,  in  order  to  determine  to 
what  extent  the  pulse  is  accelerated  in  disease,  it  is  necessary  that  it 
should  be  counted  during  a  state  of  quietude.  As  the  age  increases,  it 
is  less  and  less  influenced  by  the  emotions  and  physical  exertion ;  still, 
during  the  whole  period  of  childhood,  such  influences  do  have  more  or 
less  effect  on  its  frequenc}'. 

.Pulse  in  Disease. — Febrile  and  inflammatory  diseases  produce 
greater  acceleration  of  pulse  in  early  life  than  in  maturity.  Diseases, 
or  derangements  of  system,  particularly  those  of  the  digestive  organs, 


AXIMAL    HEAT.  99 

which  do  not  materially  affect  the  pulse  in  the  adult,  often  cause  ac- 
celeration of  it  in  children.  The  febrile  pulse  of  early  life  usually  has 
exacerbations  in  its  frequency.  These  commonly  occur  in  the  latter 
part  of  the  day.  Distinct  and  more  or  less  regular  febrile  exacerba- 
tions and  remissions  are  common  in  several  diseases  of  early  life,  some 
of  -which  are  serious,  while  others  involve  little  danger.  Among  these 
diseases  may  be  mentioned  difficult  dentition,  intestinal  worms,  incipient 
meningitis,  and  constipation.  An  intermittent  and  irregular  pulse  is 
common  in  fully  developed  meningitis  and  certain  other  severe  organic 
diseases  of  the  encephalon.  It  may  be  due  also  to  disease  of  the  heart, 
and  it  also  occurs  in  some  children  from  temporary  disturbance  of  the 
digestive  function.  The  pulse  is  slow  in  compression  of  the  brain,  and 
in  sclerema  of  the  new-born. 


Animal  Heat. 

The  internal  temperature  of  the  body  in  health  is  uniform.  In  33 
infants  under  the  age  of  seven  days,  M.  Roger  found  the  average  tem- 
perature 98.0°  Fahr.,  while  in  25,  from  four  months  to  fourteen  years 
old,  it  was  99°.  The  external  temperature  alone  varies  in  health, 
according  to  the  temperature  of  the  atmosphere. 

Elevation  of  temperature  above  the  normal  standard  is  a  sign  of  in- 
flammatory and  febrile  diseases.  The  increase  of  lieat  varies  accord- 
ing: to  the  nature  of  the  disease  and  its  tvpe.  In  favorable  cases  of 
intiammation  and  in  simple  fevers  it  is  not  ordinarily  more  than  two  or 
three  degrees.  The  greater  the  severity  and  malignancy  of  inflam- 
matory and  febrile  diseases,  the  greater  the  elevation.  An  elevation 
of  more  than  six  degrees  indicates  a  malady  which  is  likely  to  prove 
fatal.  It  is  rare  that  the  temperature,  even  in  fatal  cases,  rises  above 
107°.  In  measles,  in  the  eruptive  stage  it  is  from  101°  to  103°  ;  in 
scarlatina  from  102°  to  104°,  if  no  coinplication  exist.  In  diphtheria 
the  temperature  is  elevated  at  first,  but  it  frequently  falls  to  nearly  the 
normal  during  the  stage  of  profound  toxfemia. 

Reduction  of  tlie  internal  temperature  is  an  unfavorable  prognostic 
sijrn  ;  it  is  observed,  a  few  hours  before  death,  in  infants  who  are 
greatly  reduced  by  certain  chronic  diseases,  as  entero-colitis.  In  these 
cases  the  tonjfue  and  even  sometimes  the  breath  communicate  to  the 
finger  or  hand  a  sensation  of  coldness. 

The  importance  of  thermometric  observations,  as  an  aid  to  the  diag- 
nosis of  children's  diseases,  is  within  a  few  years  more  fully  recognized 
by  the  profession.  Two  diseases  which,  in  their  commencement,  present 
very  similar  symptoms,  often  vary  as  regards  the  temperature.  Thus, 
meningitis,  presenting  in  its  first  stages  symptoms  very  simihir  to  those 
of  typhoid  fever,  has  a  lower  temperature  till  an  advanced  stage, 
when  the  amount  of  heat  increases. 


100  DIAGNOSIS    OF    INFANTILE    DISEASES. 


Dig-estive  System. 

Inspection  of  the  buccal  and  faucial  surfaces  discloses  some  of  the  most 
frequent  local  diseases  of  infancy,  as  the  various  forms  of  stomatitis,  and 
others  which,  though  not  frequent,  involve  great  danger,  as  gangrene  of 
the  mouth,  diphtheria,  and  retro-pharyngeal  abscess.  Inspection  of  the 
tongue  aids  in  determining  in  many  cases  whether  the  disease  be  pur- 
suing a  favorable  course,  or  has  become  asthenic,  and  is  exhausting  the 
vital  powers. 

Febrile  movements,  even  when  slight,  give  rise  to  coating  of  the 
tongue,  and  intumescence  and  distinctness  of  its  follicles.  The  eruptive 
fevers  are  attended  by  changes  upon  the  buccal  and  faucial  surfaces 
which  possess  diagnostic  and  prognostic  value.  Hyperaemia  of  these 
surfaces  appears  early  in  rubeola  and  scarlatina,  prior  to  those  phe- 
nomena Avhich  are  justly  regarded  as  pathognomonic.  It  is,  therefore, 
often  an  important  sign  in  the  initial  period  of  these  diseases  when  the 
diagnosis  is  obscure.  The  appearance  of  the  fauces  in  diphtheria  and 
croup,  indicating  not  only  the  nature  of  the  disease,  but  its  gravity, 
need  only  be  referred  to  in  this  connection. 

Inspection  of  the  buccal  and  faucial  surfaces  sometimes  enables  us  to 
form  a  probable  opinion  in  reference  to  the  nature  of  diseases  which 
are  seated  in  other  parts.  In  the  infant  protracted  stomatitis  is  a 
common  accompaniment  of  chronic  diarrhoea,  and  it  indicates  its  in- 
flammatory nature. 

Vomiting  is  more  frequent  in  infancy  than  in  childhood,  and  in  either 
period  than  in  adult  life.  It  is  common  in  cerebral  affections,  and  is 
one  of  the  first  symptoms  of  scarlet  fever,  and  is  not  uncommon  though 
less  frequent,  in  the  commencement  of  the  other  essential  fevers  and  of 
acute  inflammations.  It  is  a  symptom  of  indigestion,  entero-colitis, 
cholera  infantum,  and  intussusception  ;  it  is  common,  also,  after  the 
paroxysmal  cough  of  pertussis,  and  not  infrequent  in  the  bronchial  in- 
flammations of  young  infants.  In  both  these  diseases  it  is  excited  by 
the  muco-purulent  matter  upon  the  fiiucial  surface. 

Intestinal  gas  is  in  part  secreted  or  exhaled  from  the  mucous  mem- 
brane, as  the  experiments  of  Hunter  and  others  have  shown,  and  is  in 
part  the  product  of  chemical  changes  in  the  food.  A  certain  amount 
of  gas  in  the  intestines  is  normal;  it  subserves  a  useful  purpose.  An 
abnormal  amount  of  it  is  common  in  various  diseases,  as  indigestion, 
chronic  entero-colitis,  peritonitis,  typhoid  fever.  It  is  a  frequent  cause 
of  rrastralffia  and  enteral^ria  in  tlie  infimt.  In  scrofulous  or  feeble 
infants,  with  impaired  muscular  tonicity  and  faidty  digestion,  the  abdo- 
men is  often  habitually  more  or  less  distended  with  gas,  which  does  not, 
under  such  circumstances,  give  rise  to  pain  or  other  local  symptoms ;  it 
has  significance  as  showing  the  general  condition  of  the  child. 

In  the  rachitic,  whose  thorax  is  compressed  and  liver  often  enlarged, 
while  the  vertebral  column  is  shortened,  the  abdomen  is  commonly  pro- 
tuberant. In  feeble  children,  not  decidedly  rachitic,  Avhose  lungs  are 
seldom  fully  inflated,  and  whose  chests  are  consequently  depressed,  the 
abdomen  is  also  prominent.     The  accompanying    woodcut  represents 


DIGESTIVE    SYSTEM, 


101 


Fig.  5. 


one  of  these  cases,  presented  for  treatment  at  the  outdoor  department 
at  Belleviie. 

In  feeble  children  •svlio  have  suftered  from  repeated  and  protracted 
attacks  of  bronchitis,  and  whose  chest  walls  are  consequently  depressed, 
a  similar  abdominal  prominence  occurs. 

Retraction  of  the  abdominal  walls  is  common  in  meningitis,  and  in 
many  exhausting  diseases.     Tenesmus  is  a 
symptom  of  intussusception  in  the  infant, 
and  of  colitis  in  children. 

Much  light  is  thrown  on  the  character 
of  intestinal  diseases  by  the  appearance  of 
the  stools.  Muco-sanguineous  stools  accom- 
panied by  fever,  are  a  sign  of  colitis.  Stools 
containing  unmixed  blood,  and  not  accom- 
panied by  fe\ei',  may  result  from  a  rectal 
polyj)US,  and  from  purpura  hemorrhagica. 
Scanty  evacuations  of  blood,  with  obsti- 
nate constipation,  are  a  symptom  of  intus- 
susception in  infants. 

The  alvine  discharges  of  infants  often 
present  a  green  color;  sometimes  they  have 
the  normal  yellow  hue  when  passed  from 
the  bowels,  but  become  green  on  exposure 
to  the  air,  or  from  reaction  of  the  urine. 
By  the  microscope  the  green  coloring  matter 
is  seen  to  occur  in  small,  irregular  masses. 
This  green  substance  has  been  supposed  to 
be  bile.     I  am  convmced  that,  as  it  occurs 

in  the  stools  of  the  infant,  it  is  commonly  produced  by  the  action  of 
tlie  intestinal  secretions  on  the  contents  of  the  intestines ;  for  T  have 
often  noticed  that  the  contents  in  and  above  the  jejunum  were  yellow, 
while  in  and  below  the  ileum  their  color  was  green.  Probably  tlie 
green  color  is  due  to  tlie  fornuition  of  biliverdin  from  the  bile  which  is 
mixed  with  the  fecal  matter. 

The  green  hue  may  occur  from  very  different  causes.  It  may  be  due 
to  over-feeding,  to  the  action  of  cold,  to  irritating  ingesta,  to  inflamma- 
tion, etc. ;  it  may  be  transient,  subsiding  within  a  day  or  two,  or  it  may 
continue  several  days.  All  infants,  at  times,  have  green  evacuations, 
even  when  they  appear  in  good  health. 

In  the  connnencement  of  a  large  proportion  of  diarrho'al  maladies 
in  infancy  the  stools  give  an  acid  reaction  with  litmus-paper.  This 
acid,  if  in  considerable  quantity,  is  irritating,  increasing  the  peristaltic 
movements  of  the  intestines,  and  the  functional  activity  of  the  intestinal 
follicles,  causing  erythema  of  the  skin  around  the  anus,  and  reacting 
upon  and  intensifying  the  intestinal  disease.  Hence  the  indication  for 
the  use  of  antacids  in  the  diarrlux'al  affections  of  infancy. 

Tlie  presence  of  intestinal  worms  and  the  species  may  be  ascertained 
by  microscopic  examination  of  the  stools  of  tlie  child  who  is  affected 
with  these  enfozoa.  The  stools  contain  ova,  which  differ  in  size  and 
shape  according  to  the  species  of  worm. 


102  DIAGNOSIS    OF    IXFAXTILE    DISEASES. 


Nervous  System. 

Pain. — This  symptom  affords  important  aid  to  the  physician  in  deter- 
mining the  seat  and  nature  of  the  diseases  of  children.  Pain  in  the 
head  may  occur  in  them  from  coryza  involving  the  frontal  sinuses,  or 
from  febrile  movement  in  the  commencement  of  an  essential  fever,  or 
of  inflammation  of  one  of  the  organs  of  the  trunk.  Produced  by  such 
a  cause,  it  abates  in  two  or  three  days.  If  it  be  protracted,  ■whether 
constant  or  intermittent,  it  is  in  many  cases  not  neuralgic,  as  it  so 
often  is  in  the  adult,  but  is  due  to  organic  disease  of  the  brain  or 
meninges.  Complaint,  therefore,  of  headache  in  a  child,  Avithout  any 
apparent  general  cause  or  local  cause  external  to  the  cranium,  should 
awaken  solicitude,  and,  if  it  be  protracted,  the  physician  should  ex- 
amine carefully  in  reference  to  the  presence  of  a  cerebral  or  meningeal 
disease.  Mild  frontal  headache,  continuing  for  weeks  or  months,  is 
neuralgic  and  due  to  anasmia.  It  is  increased  by  pressure  over  the 
occiput  and  upper  cervical  vertebra?. 

Grave  thoracic  or  abdominal  inflammations  in  the  adult  are  almost 
always  attended  by  a  corresponding  amount  of  pain  and  tenderness ; 
but  in  childi'cn  these  symptoms  are  often  absent,  or,  when  present,  are 
frequently  not  commensurate  with  the  amount  of  disease.  Thus,  entero- 
colitis of  nursing  infants  is,  in  a  large  proportion  of  instances,  almost 
free  from  these  symptoms. 

Pain  in  the  chest  or  abdomen,  occasional  or  constant,  continuing  for 
weeks  or  months,  Avith  fever,  and  unattended  by  tiioracic  or  abdominal 
disease,  indicates  caries  of  the  vertebi'fe.  Its  most  common  seat  is  the 
epigastric^  umbilical,  or  hypochondriac  region.  It  is  a  neuralgia  due  to 
irritation  of  the  sensitive  root  of  one  or  more  of  the  spinal  nerves.  It  is 
a  very  important  symptom  to  the  diagnostician,  shoAving  the  nature  of 
the  disease,  Avhich  in  its  incipiency  is  so  obscure.  Pain  in  the  leg, 
especially  the  inside  of  the  knee,  is  of  a  similar  character,  indicating 
disease  of  the  hip-joint. 

Children  Avith  certain  acute  febrile  and  inflammatory  diseases  some- 
times have  hypera?sthesia  of  portions  of  the  surface ;  it  is  especially 
marked  upon  the  anterior  aspect  of  the  trunk.  The  physician  might 
be  misled  into  the  belief  that  the  tenderness  occurred  over  the  seat  of 
the  disease  and  indicated  an  inflammation  ;  but  the  pain  of  hyperses- 
thesia  can  be  diagnosticated  from  that  of  inflammation  by  the  fact  that 
it  is  so  extensive,  is  less  on  firm  than  light  pressure,  and  is  especially 
observed  upon  the  inner  surface  of  the  thighs.  The  symptoms  per- 
taining to  the  nervous  system  occurring  in  the  various  diseases  treated 
of  in  this  book  Avill  be  fully  described  in  connection  with  those  diseases, 
and,  therefore,  need  not  detain  us  in  this  connection. 


THERArEUTIGS.  103 


CHAPTER  XY. 

THERAPEUTICS. 

The  young  practitioner  is  often  perplexed  in  deciding  exactly  what 
dose  of  the  stronger  and  more  dangerous  medicinal  agents  to  prescribe 
for  a  child.  A  practical  rule,  which  holds  good  for  many  medicines, 
has  been  proposed  by  Dr.  Cowling,  as  follows  :  "  The  proportional  dose 
for  any  age  under  adult  life  is  represented  by  the  number  of  the  follow- 
ing birthday  divided  by  twenty-four."  This  rule  is  inadmissible  for 
infants  under  the  age  of  six  months,  but  will  apply  for  those  that  are 
older,  for  the  use  of  a  large  number  of  medicines.  Another  rule  pro- 
posed by  another  British  physician,  Professor  Clarke,  is  based  on  differ- 
ences in  weight  of  children  and  adults :  The  adult  dose  is  represented 
by  150.  The  dose  of  a  child  is-  determined  by  dividing  its  weight  in 
pounds  by  150.  But  it  is  an  interesting  fact,  and  one  of  practical  im- 
portance, that  children  bear  and  often  require,  in  order  to  obtain  the 
desired  effect,  a  much  larger  proportionate  dose  of  certain  agents  than 
adults.  This  is  partly  attributable  to  the  active  elimination  in  child- 
hood. Belladonna  is  notably  one  of  the  agents  which  children  tolerate ; 
and  it  may  be  added  that  some  children  can  take  a  much  larger  dose 
of  it  than  others,  Avithout  producing  the  physiological  effects.  Thus, 
recently,  I  increased  gradually  the  tincture  of  belladonna  to  twelve 
drops  for  a  child  of  four  years,  Avithout  producing  the  usual  efflo- 
rescence; and  Fanpiharson  says  "the  dose  ...  I  have  pushed  in 
a  child  of  ten,  suffering  from  incontinence  of  urine,  to  fo'j  (British 
Pharmacop.)  with  good  effect,  and  the  development  of  mild  forms  of 
physiological  disturbance."  Arsenic  is  also  better  tolerated  by  children 
than  adults.  An  infant  of  six  months  can  take  two-drop  doses  of  Fow- 
ler's solution  three  times  daily  Avithout  ill-effect.  Prussic  acid,  strychnia, 
iron,  ipecacuanha,  and  alcohol,  are  also  required  in  larger  proportionate 
doses  in  childhood  than  is  indicated  by  the  rule  either  of  Dr.  CoAvling 
or  Professor  Clarke. 

"When  practicaljle,  medicines  should  be  given  in  the  li(piid  form.  1'hose 
not  soluble  may  often  be  given  in  suspension,  in  some  vehicle  Avliich  in 
great  part  disguises  the  taste.  A  good  vehicle  for  the  bitter  vegetables, 
as  the  salts  of  quinia,  is  the  elixir  adjuvans  of  Caswell  and  Hazard. 
The  following  is  the  formula  for  its  preparation : 

IJ. — Cort.  aiirant.         .         .         .         .         .         .         .  ^ij. 

Pulv.  semin.  coriundr. 

Pulv   seniin.  canii         ......  aa  ^j. 

Pulv.  cort.  pruiii  Vir^inian:e        ....  .3'^'- 

Pulv.  rad.  t,'lyc;yrrhiziu .^vj. — ^lisce. 

Menstruum,  Alcohol     .......  partis  j. 

Aquic part.  ijss. — Misce. 

Percolat.  O.  v,  et  adde — 

Syr.  .simplic.  ....... 

Aquae Sa  Oi.iss. 


lU-i  THERAPEUTICS. 

The  elixir  adjuvans  may  also  be  advantageously  employed  in  the  ad- 
ministration of  many  other  medicines  apart  from  those  which  are  repul- 
sive on  account  of  their  bitterness.  It  holds  them  in  suspension  so  that 
if  they  have  a  greater  specific  gravity  than  the  elixir  it  is  necessary  to 
shake  the  bottle  thoioughly  before  using  it.  The  elixir  taraxaci  comp. 
is  another  good  vehicle  for  bitter  vegetables,  although,  like  the  elixir 
adjuvans,  not  officinal.  I  am  sure  from  many  observations,  that  un- 
pleasant doses  are  apt  to  be  Avasted  to  a  greater  or  less  extent,  and  the 
repugnance  of  children  to  medicines  emplo3^ed  has  induced  many  a 
parent  to  seek  other  and  less  disagreeable  modes  of  treatment.  Chem- 
istry has  greatly  aided  the  therapeutics  of  childhood,  in  that  it  has 
enabled  us,  in  so  many  instances,  to  prescribe  the  active  principles  in 
place  of  the  large,  nauseous  doses  formerly  employed. 


PART  II. 

CONSTITUTIOXAL  DISEASES. 


SECTION  I. 

DIATHETIC  DISEASES. 


CHAPTEK    I. 

EACHITIS. 

Rachitis,  or  rickets,  is  regarded  as  a  constitutional  disease,  though 
the  symptoms  and  lesions  Avhich  characterize  it  pertain  chiefly  to  one 
of  the  systems.  It  occurs  in  the  first  years  of  life,  and,  therefore, 
during  the  period  of  most  active  growth  of  the  skeleton.  It  is  mani- 
fested by  an  abnormal  nutrition  and  changed  physiological  action  of  the 
bone-producing  tissues,  namel}^  the  epiphyseal  cartilage  and  the  peri- 
osteum, and  by  the  arrest,  more  or  less  complete,  of  the  deposition  of 
lime-salts  in  these  tissues. 


Frequency  of  Rachitis. 

Rachitis  is  a  common  result  of  faulty  diet  and  of  antihygienic  con- 
ditions, and  is,  therefore,  frequent  among  the  poor  of  cities,  and 
especially  in  families  who  dwell  in  crowded  tenement  houses.  It  has, 
heretofore,  been  prevalent  in  the  city  infantile  asylums,  but  of  late 
years,  as  regards  at  least  the  city  of  New  York,  it  is  much  less  common, 
in  conseijuence  of  the  greater  attention  now  given  to  sanitary  re(iiiire- 
ments  in  the  management  of  tliese  institutions.  Mild  cases  of  rickets 
are  often  overlooked,  since  physicians  may  not  be  summoned  to  attend 
them,  while  even  if  they  be  summoned,  many,  who  have  not  given 
particular  attention  to  this  disease,  are  apt  to  err  in  diagnosis,  and  to 
refer  the  symj)tonis  to  some  other  than  the  true  cause.  Coniineiicing 
gradually  and  insidiously,  rachitis  not  infre((Mently  continues  for  nioiitlis, 
even  in  its  typical  form,  before  a  correct  diagnosis  is  ni;ide.  In  the 
absence  of  deformity,  which  is  a  late  symptom,  the  fretfulness,  tender- 
ness of  surface,  and  perspirations,  receive  a  wrong  explanation.     Prac- 

( io.> ) 


106  RACHITIS. 

titioners  who  have  heretofore  given  little  attention  to  this  malady,  and 
"Nvho  believe  it  to  be  rare,  if  they  are  instructed  in  reference  to  its 
characteristic  signs,  and  look  for  them  in  their  visits  among  the  city 
poor,  are  surprised  at  the  numl;er  of  cases  with  "which  they  meet.  A 
few  years  since,  in  the  New  York  Infant  Asylum,  my  attention  was 
directed  to  a  rachitic  child,  whose  head  had  so  changed  from  the  normal 
shape,  that  the  nurses,  as  well  as  the  physician,  had  remarked  the  dif- 
ference. Prompted  by  the  occurrence  of  this  case,  which  had  gradually 
developed  under  my  eyes,  I  made  a  careful  examination  of  all  the 
infants,  and  discovered,  what  I  had  not  previously  suspected,  that  about 
one  in  nine  had  become  rachitic.  In  most  of  the  infants  the  disease 
was  mild,  but  with  symptoms  so  characteristic  that  it  was  readily  recog- 
nized. By  effecting  certain  improvements  in  the  diet,  among  which 
was  the  daily  allowance  of  beef-tea  to  the  older  infjints,  rachitis,  unless 
of  a  mild  type,  has  since  been  rare  in  this  institution. 

The  late  Dr.  John  S.  Parry,  of  Philadelphia,  stated  that  at  least 
twenty-eight  per  cent,  of  all  the  children,  between  the  ages  of  one 
month  and  five  years,  who  came  under  his  observation  in  the  Phihvdel- 
phia  Hospital  during  the  three  years  preceding  the  publication  of  his 
paper,  in  1872,  Avere  rachitic.  This  is  certainly  a  larger  proportion 
of  those  who  present  indubitably  rachitic  symptoms  than  occurs  in  any 
of  the  three  New  York  institutions  for  children  with  which  I  have  an 
official  connection.  In  the  New  York  Foundling  Asylum,  with  its  six- 
teen hundred  inmates,  and  in  tlie  Bureau  for  the  Relief  of  the  Out-door 
Poor,  where  over  eight  thousand  children  are  annually  treated,  rachitis 
is  certainly  less  frequent  than  is  indicated  by  the  statistics  of  Dr.  Parry. 
In  Europe,  from  the  testimony  of  many  observers,  both  continental  and 
British,  rickets  is  very  common  among  tlie  flimilies  who  seek  medical 
advice  in  the  institutions  of  charity.  Ritter  von  Rittershain  finds  that 
thirty-one  per  cent,  of  all  the  children  who  are  brought  to  the  Prague 
Medical  "  Poliklinik,"  are  rachitic,  and  Prof.  Henoch  states  that  the 
proportion  is  equally  large  in  the  families  of  Berlin,  who  are  in  similar 
reduced  circumstances.  According  to  Dr.  Gee,  whose  statement  was, 
however,  made  as  far  back  as  1867-68,  of  the  patients  under  the  age 
of  two  years,  in  the  London  IIosj)ital  for  Sick  Children,  30.8  per  cent, 
are  rachitic.  Both  Dr.  Hillier  and  Sir  Wm.  Jenner  not  only  allude  to 
the  frequency  of  rachitis,  but  state  that  it  is  the  cause  of  many  deaths 
in  London  families.  It  appears,  therefore,  that  this  malady,  though 
not  rare  in  American  cities  where  ill-fed  and  ill-housed  families  con- 
gregate, is  less  prevalent  than  in  families  similarly  situated  in  Europe. 
The  greater  immunity  in  this  country  must  be  due  to  otlier  causes  besides 
difference  in  nationality,  for  tlie  poor  of  American  cities  are  largely  of 
foreign  birth. 

But  rachitis  does  not  occur  exclusively  among  the  poor.  Children 
of  well-to-do  families  are  also  liable  to  it,  provided  that  the  conditions 
soon  to  be  enumerated  are  present.  Ignorance  or  disregard  of  the 
hygienic  re([uirements  of  young  children,  and  especially  the  use  of 
improper  diet,  leads  to  the  develoimient  of  rachitis  in  wealthy  as  well 
as  in  destitute  fiimilies.  Merei,  in  his  treatise  on  the  .Disorders  of 
Infantile   Development  (London,    1855),   states   that  in   Manchester, 


AGE    AT    WHICH     RACHITIS    OCCURS. 


10^ 


where  liis  observations  Avere  made,  one  child  in  every  five,  in  families 
in  comfortable  circumstances,  presented  rachitic  symptoms ;  and  he  be- 
lieves that  this  cannot  be  much  above  the  real  proportion  in  "  the  whole 
of  the  wealthy  classes." 

Rachitis,  in  its  milder  form,  is  not  uncommon  in  affluent  families  in 
this  country,  the  cause  of  the  delayed  dentition,  the  fretfulness,  and  per- 
spiration, not  being  suspected  in  many  instances,  as  I  have  had  oppor- 
tunities to  observe.  Often  family  physicians  are  not  consulted  in 
reference  to  such  symptoms,  and  when  they  are  called  in,  so  little 
attention  has  rachitis  received  on  the  part  of  many  practitioners,  that 
they  are  very  apt  to  overlook  the  true  pathological  state  ^hich  is  present. 
Still,  admitting  the  fact  that  many  cases  are  not  diagnosticated,  I  repeat 
that,  though  rachitis  is  not  uncommon  on  this  side  of  the  Atlantic,  its 
jiercentagc  of  frequency  falls  below  that  observed  in  European  cities,  a 
fact  Avhich  may  be  due  to  less  crowding  in  their  domiciles,  and  to  a 
more  liberal  and  better  supply  of  food  among  the  families  of  the  poor 
in  this  countrv. 


Fir. 


Age  at  -which  Rachitis  Occurs. 

Rachitis  is,  with  few  exceptions,  a  disease  of  infancy,  commencing 
prior  to  the  age  of  two  and  a  half  yeax-s.  Now  and  then,  it,  or  a  state 
closely  resembling  it,  occurs  in  the  fortus,  causing 
deformities,  such  as  are  present  in  typical  cases. 
In  the  Kinderspital  Museum,  at  Prague,  is  a  spec- 
imen showing  this,  and  described  by  Hitter.  Ilink 
and  Winkler  also  describe  such  cases,  and  Virchow 
alludes  to  a  specimen  in  the  Wurzburg  Museum, 
which  exhibits  such  deformities  as  characterize 
lachitis.  Jjcdnar  even  regards  foetal  rachitis  as  not 
uncommon  (Ilillicr,  Parry).  In  the  Wood  Museum 
of  ]3ellevue  Hospital,  is  a  skeleton  Avhich  is  prol)- 
ably  similar  to  those  in  the  Prague  and  Wurzburg 
Museums.  It  shows  in  a  striking  manner  the 
deformities  of  this  congenital  disease.  The  case 
occurred  in  my  practice,  and  the  dissection  was 
made  by  Prof  Francis  Delafieid.  The  infant,  born 
at  term,  died  a  few  hours  after  birth  from  atelectasis, 
:i|)parently  produced  by  the  contracted  state  of  the 
thoracic  walls.  The  parents  were  hard-Avoiking 
Engli.sh  people,  whose  mode  of  life  and  surroundings 
Were  such  as  are  known  to  conduce  to  rachitis. 
They  were  free  from  syi)hilitic  taint.  The  accom- 
panying Avoodeut  (Fig.  0)  represents  this  skeleton. 

The  f  )lKjwing  remarkable  ca.se  of  supposed  foetal 
rachitis  was    related  to   me   by  Heitzmann,  Avho.se  interesting  experi- 
ments Avill  be  ])resently  detailed: 

C.v.sK  1. — A  woman  Avho  had  frequently  injjaled  the  vapor  of  lactic 
acid  cacii  day,  for  many  month.s,  as  she  w;is  employed  to  feed  animals 


Skeleton  of  II  rarliitir; 
infant  which  Uicl  a  iow 
liDUrs  uftor  birth. 


108  RACHITIS. 

^vith  this  agent,  gave  birth  to  an  infant,  at  term,  Avhich  died  immediately 
after  it  was  born.  It  exhibited  the  signs  of  congenital  rachitis  in  a  high 
degree.  The  skull  bones  were  completely  absent;  in  the  cartilages  of  the 
bones  of  the  extremities,  and  in  those  of  the  ribs,  there  were  scanty 
depositions  of  lime-salts,  and  numerous  infractions.  The  death  of  the 
child  was  evidently  due  to  the  absence  of  the  skull  bones,  inasmuch  as 
the  pressure  of  the  womb  during  delivery  had  caused  cerebral  hemor- 
rhage. All  the  organs  of  the  chest  and  abdomen  were  found  in  full 
development  and  healthy. 

We  will  see,  hereafter,  that  the  theory  which  attributes  rachitis,  in 
certain  instances,  to  a  chemical  irritant,  is  sul)stantiattd  by  experiment, 
and  that  it  has  already  been  shown  that  two  such  agents,  phosphorus  and 
lactic  acid,  may  cause  this  disease.  !N^ow,  as  the  irritating  action  of 
phospliorus  on  the  osseous  system  occurs  when  it  is  inhaled  in  the  form 
of  vapor,  as  well  as  when  received  in  the  ingesta,  so  lactic  acid,  if  the 
above  case  be  rightly  interpreted,  produces  its  special  effect  U{)on  the 
bone-producing  tissues  when  inhaled,  as  decidedly  as  when  received  in 
the  ingesta  or  generated  in  the  system.  These  remarks  seem  necessary 
for  an  understanding  of  this  unusual  case,  although  they  anticipate  what 
will  be  said  under  the  head  of  etiology.  In  the  New  York  Journal  of 
Obstetrics  for  November,  1870,  Prof.  Aln-aham  Jacobi  also  published 
the  description  of  a  case  of  congenital  rachitic  craniotabes.  AVhether 
or  not  Ave  accept  as  genuine  all  the  reported  cases  of  fcctal  rachitis, 
there  can  be  little  doubt,  from  the  number  of  observations  already  made 
and  carefully  recorded,  and  from  the  opinion  of  high  authorities  like 
Virchow,  that  such  cases  do  occur. 

Enlargement  of  the  costo-chondral  articulations  known  as  the  "  ra- 
chitic rosary,"  which  is  one  of  the  earliest  and  most  reliable  signs  of 
rickets,  has  been  observed,  though  rarely,  in  infants  only  a  few  weeks 
old.  Dr.  Parry  saw  it  as  early  as  the  sixth  week  after  birth,'  and  Dr. 
Gee  at  the  third  or  fourth  week.^  This  should  not,  however,  be  regarded 
as  a  sign  of  rachitis,  unless  the  enlargement  be  so  great  that  it  can  be 
readily  appreciated  by  examination  through  the.in tegument,  or  by  sight, 
for  in  young  cliildren,  with  the  bones  in  the  process  of  normal  develop- 
ment, these  joints  usually  have  a  diameter  a  little  larger  than  that  of 
the  ribs.  Rachitis,  with  few  exceptions,  begins  Avithin  the  first  eighteen 
months  of  life.  Though  first  detected  and  diagnosticated  at  a  later 
date,  it  will  ordinarily  be  ascertained,  on  inquiry,  that  its  symptoms 
had  an  earlier  beginning.  Still,  according  to  certain  observers,  it  may 
have  a  considerably  later  commencement.  Glisson,  P(»rta],  and  Tripier 
state  that  they  have  seen  it  commence  in  children  Avho  Avere  Avell  on 
toward  the  age  of  puberty.  Sir  Wm.  Jenner  states  that  he  has  seen 
children  of  seven  and  eight  years,  Avho  Avere  only  beginning  to  suffer 
from  rachitis.* 

The  folloAving  are  the  aggregate  statistics  of  Bruennische,  von  Rit- 
tershain,  and  liitsche,  relating  to  the  age  at  Avhich  rachitis  occurs : 

*  American  Jouriiul  of  the  ^Medical  Sciences,  January.  1872. 
2  St.  Bartholomew's  H'ispital  Reports,  vol    iv. 
»  Lancet,  December  11,  1880. 


CAUSES.  109 


No.  of  Cases. 

During  the  first  half  year,    ........       99 

"         "    second  half  of  first  vear,    ......     259 

"         "         "       year,        .      ' 342 

"         "    third  year, 134 

"         "    fourth  year,        .         .         .         .         .         .         .         .31 

"         "    fifth  year, 17 

Between  the  fifth  and  ninth  years,       ......       21 


Aggregate, 903 


Causes  of  Rachitis. 


Inheritance. — In  some  infants  there  is  an  undoubted  hereditary 
predisposition  to  rachitis.  .  Feeble  digestion  and  defective  assimihttion 
in  the  infant,  which  are,  as  we  shall  see,  important  factors  in  producing 
the  rachitic  state,  are  often  traceable  to  disease  or  cachexia  of  one  or 
both  parents.  The  offspring  of  a  tubercular,  syphilitic,  or  otherwise 
enfeebled  parent,  is  more  likely  to  become  rachitic  than  those  of  healthy 
and  robust  ancestry  ;  and  it  appears  that  disease  of  the  mother  is  more 
apt  to  entail  a  rachitic  predisposition  than  that  of  the  father.  Among 
the  parental  causes  may  be  mentioned  poverty,  hardships,  and  defective 
nutrition  of  either  parent ;  age  of  the  father,  and  exhausting  discharges 
of  the  mother,  such  as  purulent,  hemorrhoidal,  or  uterine  fluxes. 

Food. — Of  the  exciting  causes,  the  most  common  is  the  use  of  food 
not  sufficiently  nutritive,  or,  if  nutritious,  not  suited  to  the  age  and 
digestive  powers  of  the  child.  Thin  and  poor  breast-milk,  and  artifi- 
cial food  of  poor  quality,  or  not  suitable  for  the  stage  of  growth  and 
development,  are  common  causes  of  rickets.  Those  children  who  have 
been  prematurely  weaned,  and  who  have  been  given  a  food  which  is  not 
a  proper  substitute  for  the  natural  aliment,  and  those  too  long  wet- 
nursed  and  not  allowed  the  additional  nutriment  which  they  re(iuire,  are 
especially  liable  to  this  disease.  Those  whose  digestive  power  is  feeble, 
from  whatever  cau.se,  are  more  apt  to  become  rachitic  than  those  who, 
in  a  state  of  robust  health,  have  a  hearty  digestion.  Hence  we  meet 
with  rickets  as  a  sequel  of  various  protracted  and  exhausting  maladies 
during  infancy. 

It  might  be  supposed,  from  the  nature  of  rachitis,  that  the  use  of 
food  deficient  in  piiosphoric  aci«l  and  lime  is  the  common  cause  of 
rachitis;  but  facts  show  that  this  is  not  the  correct  view  of  its  etiology, 
as  it  commonly  occurs,  although  in  its  treatment  these  agents  are  of 
undoubted  value.  The  disturbed  and  altered  nutrition  of  the  osteo- 
plastic tissues,  namely  of  the  epiphyseal  cartilage  and  the  periosteum, 
is  the  important  factor  in  producing  the  rachitic  bone  disease,  and  tiiis 
may  occur  although  the  ingesta  contain  a  sufficient  amount  of  phos- 
phoric acid  and  lime.  Deficiency  of  these  substances  probably  tends  to 
diminish  the  amount  of  lime  deposition,  but  it  is  not  the  essential 
element  in  the  causation  of  the  malady.  Tiiis  is  to  be  found  in  the 
unhealthy  condition  and  action  of  the  cartilage  and  periosteum,  or 
rather  in  the  agencies,  now  partly  ascertained,  which  produce  the 
abnormal  state  and  altered  nutrition  of  these  tissues. 


110  RACHITIS, 


Artificial  Production  of  Rachitis. 

The  important  fact  has  been  ascertained  by  experiments  on  young 
animals,  that  rachitis  can  be  produced,  as  I  have  already  stated,  by  at 
least  two  chemical  agents,  which  may  be  admitted  into  the  system  in 
the  ingesta,  and  which  exert  an  especially  irritating  action  on  the  osteo- 
piastic"  tissues.  Senator  states,  in  Ziemssen's  IJnnjcIopa'dia,  that 
"Wegner  .  .  .  has  recently  brought  experimental  evidence  to 
show  that  true  rickets  may  be  artificially  produced  by  the  continued 
administration  of  very  minute  doses  of  phosphorus  .  .  .  together 
Avith  a  simultaneous  withdrawal  of  lime  from  the  food."  The  fact 
being  established  that  it  is  possible  to  produce  rickets  by  certain  dele- 
terious principles  in  the  ingesta,  opens  an  interesting  field  for  experi- 
mental inquiry.  Since  improper  feeding  and  indigestion  are  known  to 
sustain  a  causative  relation  to  rachitis,  experiments  have  been  made  to 
ascertain  whether  some  chemical  agent,  developed  in  the  system  during 
the  dicrestive  process,  or  introduced"with  the  food,  may  not  cause  rachitis 
as  it  o^'rdinarily  occurs  in  the  infant.  Among  the  foremost  in  that  line 
of  experiment  has  been  Dr.  Heitzmann,  a  resident  of  A' ienna  when  his 
observations  were  made,  but  now  a  citizen  of  New  York. 

In  young  children,  acids,  especially  the  lactic,  are  commonly  produced, 
and  often  in  large  quantities,  as  the  result  of  improper  feeding,  of  indi- 
gestion, and  of  intestinal  catarrh.  The  acidity  of  the  infant's  stools, 
under  such  conditions  of  ill-health,  is  well  known.  What  more  natural, 
then,  than  the  supposition  or  belief  that  this  acid,  thus  generated, 
sustains  the  same  causative  relation  to  rickets,  as  phosphorus  in  the 
experiments  which  have  been  made  with  that  agent.  But  the  acid 
which  is  produced  so  abundantly  in  disturbed  states  of  the  digestive 
apparatus  in  the  infant,  believed  to  be  chiefly  the  lactic,  must,  in  order 
to  reach  the  bones  and  influence  their  nutrition,  pass  through  the  blood, 
which  is  always  alkaline.  This  difficulty  in  the  way  of  the  theory  that 
lactic  acid  is  the  irritating  agent,  is  removed  by  physiologists,  Avho  tell 
us  that  among  the  organic  acids  the  existence  of  lactic  acid  m  healthy 
blood  is  not  entirely  beyond  doubt,  but  that  it  has  been  found  in  the 
latter  under  abnormal  conditions.^  Lactic  acid  has  also  been  found, 
after  having  made  the  circuit  of  the  system,  in  the  excretion  from  the 

kidnevs.  . 

Heitzmann,  in  order  to  ascertain  whether  this  acid  sustained  a  causa- 
tive relation  to  rickets,  made  a  series  of  experiments,  which  have  passed 
into  the  literature  of  this  disease,  and  he  has  kindly  furnished  me  with 
their  details,  as  follows :  i  p       i   /■ 

"Marchand,  Ragsky,  Lehman,  Simon,  and  others  have  iound  tree 
lactic  acid  in  the  urine  of  persons  suffering  from  rickets  and  osteo- 
malacia. C.  Schmidt  discovered  lactic  acid  in  the  luiuid  of  malacic 
shaft-bones  which  were  transformed  into  globular  cysts.  Encouraged 
by  these  chemical  researches,  I  undertook  a  series  of  experiments  on 
the  action  of  lactic  acid,  administered  both  by  the  mouth  and  by  sub- 

1  Heinrich  Frcy,  of  Zurich. 


ARTIFICIAL    PRODL'CTIOX.  IH 

cutaneous  injection,  upon  the  bones  of  living  animals,  which  experi- 
ments Avere  begun  in  April,  1872,  and  continued  until  the  end  of 
October,  1873.  The  experiments  were  made  upon  five  dogs,  seven  cats, 
tAvo  rabbits,  and  one  squirrel.  On  dogs  and  cats  under  one  year  of  age, 
the  lactic  acid,  given  either  by  mouth  or  injection,  in  combination  Avith 
restricted  administration  of  calcareous  food,  produced  swelling  of  the 
epiphyses  of  the  shaft-bones  and  of  the  anterior  ends  of  the  ribs,  at 
their  attachments  to  the  costal  cartilages.  This  result  was  plain  in  the 
second  Aveek  after  the  beginning  of  the  lactic  acid  treatment.  Up  to 
the  fourth  and  fifth  Aveeks,  the  swelling  of  the  epiphyses  and  of  the 
ends  of  the  rilts  kept  increasing,  and  then  Avas  accompanieii  by  curva- 
tures of  the  bones  of  the  extremities.  As  accompanying  symptoms,  I 
noticed  catarrhal  inflammation  of  the  conjunctiva,  of  the  mucosa  of  the 
bronchi,  the  stomach,  and  the  intestines,  Avith  emaciation  and  convulsiA^e 
movements  of  the  extremities.  The  microscopic  examination  of  the 
epiphyses  gave  an  image  fully  identical  Avith  that  of  the  epi})hyses  of 
rickety  children.  Upon  continuing  the  administration  of  the  lactic 
acid,  the  SAvelling  of  the  epiphyses  of  the  shaft-bones  gradually  increased, 
and  so  did  the  curvatures  of  the  same  bones.  After  four  or  five 
months  of  lactic  acid  treatment,  under  often  repeated  catarrhal  inflam- 
mations of  the  above-named  mucous  layers,  the  shaft-bones  became  soft 
to  such  a  degree  that  they  couhl  be  bent  like  the  branches  of  a  AvilloAv- 
tree.  After  from  four  to  eleven  months  of  the  same  treatment,  the 
microscopic  examination  of  the  bones  gave  a  result  corresponding  Avith 
that  obtained  from  the  bones  of  women  Avho  have  died  Avith  osteomalacia. 

"  On  the  three  herbivorous  animals  no  swelling  of  the  epi])hA'ses  Avas 
noticeable.  One  rabbit  died  three  months  and  the  other  five  months 
after  the  commencement  of  administration  of  the  lactic  acid,  but  Avith 
symptoms  of  inanition.  No  marked  evidences  of  rachitis  or  malacia 
were  traceable  in  the  bones  of  these  animals.  The  squirrel,  on  the 
contrary,  Avhich  died  after  thirteen  months  of  treatment  Avith  lactic 
acid,  gave  all  the  features  of  osteomalacia. 

'"Ml/  expcriinentH  (jive  the  result  that  hy  continuous  administration 
of  lactic  acid,  at  first  rickets,  and  afterwards  osteomalacia,  can  he 
artificialhf  produced  in  flesh-eaters ;  while  in  herbivorous  animals, 
osteomalacia  sets  in  without  preceding  symptoms  of  rickets.  Through 
these  experinu-nts  I  have  proA-ed  the  identity  in  nature  of  these  tAvo 
diseases,  the  differences  in  their  course  beinj;  due  to  the  difference  in 
the  age  at  Avhich  the  .'^ohition  of  the  lime-salts  is  cs^^ablished. 
Kickets  can  be  produced  on  dogs  and  cats  only  under  the  age  of  ten  or 
twelve  months.  Mr.  Hess  fed  Avith  lactic  acid  a  dog  of  the  age  of  one 
and  a  half  years,  and  failed  to  produce  rickets.  This  result  is  in  full 
agreement  Avith  my  experiments.  I  maintain  tint  lactic  acid,  tliough 
not  free  in  the  blood,  if  in  contact  Avith  the  tissues  producing  bone,  or 
with  fully  developed  bone,  OAving  to  its  great  affinity  for  lime,  either 
prevents  the  formation  of  bone  (rickets),  or  dissolves  ready-made  bone 
^osteomalacia)." 

On  the  other  hand,  rachitis  sometimes  occurs  in  infants  wlio  present 
no  history  of  indigestion  or  of  intestinal  catarrli,  and  in  wliom  there  "s 
no  ground  for  the  belief  that  lactic  or  any  other  acid  is  produced  in 


112  RACHITIS. 

undue  or  injurious  quantity.  In  a  considerable  proportion  of  such  cases, 
inquiry  elicits  the  fact  of  antihygienic  conditions,  but  there  is  no  evi- 
dence of  imperfect  digestion,  or  of  gastro-intestinal  catarrh,  such  as 
produces  lactic  acid.  In  the  cases  occurring  in  the  New  York  Inftxnt 
Asylum,  alluded  to  above,  some  of  the  children  had  manifest  gastro- 
intestinal derangement;  but  others,  Avho  Avere  wet-nursed,  gave  no  evi- 
dence of  faulty  digestion,  though  the  nutriment  which  they  received  was 
probably  insufficient ;  for,  as  already  stated,  by  providing  a  more  liberal 
diet,  by  allowing  among  other  articles  the  juice  of  meat,  rachitis  became 
much  less  frequent,  and  is  seldom  observed  at  present  among  the  infants 
of  that  institution,  unless  in  a  very  mild  form. 

VirchoAV  and  others  have  suggested  that  the  pi'ime  factor  in  causing 
rachitis  is  the  use  of  a  diet  that  is  deficient  in  calcareous  salts,  and  we 
have  seen  that  in  the  interesting  experiments  of  Dr.  Heitzmann,  the 
administration  of  calcareous  food  to  the  animals  Avas  restricted.  Still, 
as  Niemeyer  has  Avell  said,  deprivation  or  restricted  use  of  the  chalky 
salts  cannot  possibly  cause  the  most  important  histological  change  in 
rachitis,  namely,  the  proliferation  of  the  epiphyseal  cartilages  and 
periosteum,  and  Ave  must  look  for  some  other  factor  in  the  causation. 

Pathology  furnishes  many  examples  of  chronic  disease  attended  by 
proliferation  of  tissue,  the  causes  of  Avhich  are  not  uniform.  Cirrhosis, 
Avitli  its  proliferation  of  hepatic  connective  tissue,  Avhich,  as  Ave  shall 
see,  presents  a  similitude  in  some  respects  to  rachitis,  is  sometimes 
undoubtedly  produced  by  the  irritating  action  of  a  chemical  agent,  to 
Avit,  alcohol ;  but  all  physicians  knoAV  that  there  are  many  cirrhotic 
patients  Avho  refrain  entirely  from  the  use  of  alcohol  in  any  form.  In 
like  manner,  it  seems  to  me  that,  if  Ave  admit,  as  Ave  must  in  the  light 
of  experiments,  that  certain  chemical  agents,  notably  phosphorus  and 
lactic  acid,  introduced  into  the  system  or  produced  in  it,  cause  rachitis 
by  their  irritating  action,  there  are  other  typical  cases  in  Avhich  there  is 
no  reason  to  suspect  the  operation  of  such  agents.  We  must,  therefore, 
remain  in  the  belief  that  rachitis,  like  many  other  pathological  pro- 
cesses, does  not  result  from  a  fixed  and  uniform  cause,  but  from  con- 
ditions Avhich  A'ary  to  a  certain  extent  in  different  patients. 


Anatomical  Characters  of  Rachitis. 

For  conA^enience  of  description,  the  course  of  rachitis  is  diAdded  into 
three  periods:  (1)  That  of  proliferation  and  altered  nutrition  of  car- 
tilage and  periosteum ;  (2)  That  of  curvature  and  deformity  ;  (3)  That 
of  reconstruction. 

Anatomical  Characters  ix  the  Stage  of  Proliferation  and 
Altered  Nutrition. — Ossification  of  a  long  bone  occurs  from  the 
epiphyseal  cartilages,  and  from  the  periosteal  or  fibrous  membrane 
Avhich  surrounds,  nourishes,  and  protects  the  bone.  GroAvth  in  length 
is  from  the  former,  in  thickness  from  the  latter.  As  regards  the  flat 
!)one,  Avhile  groAvth  in  thickness  occurs  from  the  periosteum,  that  in 
breadth  is  from  the  cartilage  of  its  border,  Avhich  corresponds  with  the 
epiphyseal  cartilage  of  the  long  bone. 


ANATOMICAL    CHARACTERS.  113 

Cartilaginous  Changes. — If  we  examine  the  epiphyseal  cartilage  of 
a  long  bone  during  normal  ossification,  we  observe,  first  beginning  at 
the  distal  end,  a  Avhite  zone,  consisting  of  a  hyaline  matrix,  in  which 
are  the  usual  cartilage  cells.  This  constitutes  most  of  the  cartilage. 
Underneath  this,  and  nearer  the  bone,  is  the  zone  of  prolifo'ation,  the 
cartilage  in  which  is  softer  and  more  yielding  than  that  of  the  distal 
zone,  in  consequence  of  cell  formation,  and  absorption  of  the  matrix  to 
make  way  for  cell-groups.  Each  cartilage  cell  in  the  proliferating  zone 
has  divided  into  two  cells,  and  each  of  these  cells  into  two  other  cells, 
and  the  division  has  been  repeated  so  that  eight  cells  instead  of  one 
are  observed,  surrounded  by  a  common  capsule.  The  cnpsule  becomes 
distended  by  the  cell  multiplication,  and  by  the  swelling  of  each  cell, 
the  size  of  Avhich  is  considerably  greater  than  that  of  the  parent  cell. 
Near  the  bone,  namely,  along  the  extremity  of  the  diaphysis,  the  cell- 
uroups,  enclosed  in  their  capsules,  nearly  touch  each  other,  the  matrix 
naving,  for  the  most  part,  been  absorbed.  The  end  of  the  diaphysis  is 
covered  with  a  layer  of  these  cell-groups,  about  to  undergo  ossification, 
with  almost  no  intervening  matrix.  The  proliferating  zone  has  very 
little  depth.  It  appears  to  the  naked  eye  as  a  very  thin,  scarcely  per- 
ceptible layer  of  a  reddish-gray  color  upon  the  end  of  the  shaft.  It  is 
so  shallow  that  it  does  not  perceptibly  increase  the  thickness  of  the 
cartilage. 

In  rachitis,  the  state  of  affairs  is  different.  The  zone  of  proliferation, 
instead  of  being  confined  to  a  single,  or  at  most  a  double,  layer  of  cell- 
groups,  consists  of  many  layers  involving  nearly  the  whole  epiphyseal 
cartilage.  The  cells,  still  enclosed  in  their  distended  capsules,  undergo 
a  more  frequent  division  than  in  health,  so  that  instead  of  groups  of 
eight  cells,  as  in  the  normal  state,  each  group  consists  of  from  thirty  to 
forty  cells.  Therefore,  in  rachitis,  the  proliferating  cartilaginous  zone 
is  a  broad  cushion,  very  soft,  of  a  grayish  translucent  appearance,  causing 
the  characteristic  swelling  observed  around  the  joint.  Over  the  distal 
end  of  the  proliferating  cartilage,  there  may  still  be  a  layer  or  zone, 
though  perhaps  of  little  depth,  of  normal  cartilage,  like  that  in  health. 

Osseous  Changes. — While  this  occurs,  the  ossifying  process  is  also 
arrested.  We  indeed  perceive  an  effort  in  the  direction  of  bone  forma- 
tion. The  Haversian  canals,  surrounded  by  capillary  loops,  extend 
from  the  bone  into  the  proliferating  zone  of  cartilage.  Their  extension 
is  effected  by  absorption  of  the  matrix  and  appropriation  of  cell-groups 
which  lie  in  their  way.  The  cells  in  these  groups,  as  they  enter  the 
Haversian  system,  become  much  smaller  by  a  rapid  segmentation, 
forming  medulbuy  cells.  We  also  fin<l,  as  further  evidence  of  the 
attempt  at  bone-formation,  granules  and  masses  of  lime  scattered 
tlirough  the  cartilage,  and  here  and  there  spicul?e  and  nodules  of  true 
bone,  springing  up  from  the  bony  substratum  of  the  shaft.  Some  of 
the  canals  extend  far  into  the  cartilage,  nearly  indecil  to  its  free  surface, 
but  most  of  them  terminate  in  its  lowest  portion.  The  growth  of  bone 
in  thickness  occurs  from  the  under  surface  of  the  periosteum.  In 
health,  a  soft,  vascular,  germinal  tissue  springs  from  the  periosteal 
surface,  and  rapidly  receives  lime-salts,  and  is  transformed  into  bone. 
This  germinal  tissue,  consisting  largely  of  capillaries  arising  from  the 

8 


114 


RACHITIS. 


fibrous  tissue  of  the  periosteum,  is  ti  very  thin  substratum,  barely  visible, 
transient,  and  constantly  changing,  from  its  conversion  into  bone. 

In  rachitis,  this  vascular  subperiosteal  tissue,  not  undergoing,  or 
undergoing  slowly  and  imperfectly,  the  osseous  transformation,  and  at 
the  same  time  increasing  more  rapidly  than  in  health,  uiuler  the  irritat- 
ing influence  of  the  rachitic  disease  becomes  a  thick  layer.  Its  color 
and  appearance  are  like  spleen  pulp,  so  that  the  older  observers  sup- 
posed there  was  a  hemorrhagic  extravasation  between  the  periosteum 
and  the  bone.  There  is,  however,  no  extravasation  of  blood,  unless  it 
accidentally  occur  from  the  numerous  delicate  capillaries.  The  resem- 
blance to  extravasated  blood,  or  spleen  pulp,  is  due  to  the  abundant 
growth  of  large  and  thin-walled  capillaries  from  the  under  surface  of 
the  periosteum,  as  shown  by  the  microscope.  This  vascular  outgrowth 
is,  for  the  most  part,  quite  uniform  over  the  diaphysis  of  the  long  bones, 
Avhile  upon  the  cranial  bones  its  thickness  is  much  greater  in  one  locality 
than  in  another.  The  attempt  at  ossification  also  appears  in  this  tissue. 
Lime-salts  are  scantily  and  loosely  deposited  through  it,  forming  osteo- 
phytes— vascular  and  fragile — rather  than  true  bone. 

The  question  naturally  arises,  llow  does  rachitis  affect  bone  which  is 
already  formed  when  the  rachitic  state  begins  ?  Virchow's  answer  is 
the  following:  "  Rachitis  has  .  .  .  by  more  accurate  investigation 
been  shown  to  consist,  not  in  a  process  of  softening  in  the  old  bone,  as 
it  had  previously  been  considered  to  be,  but  in  a  non-solidification  of 
the  fresh  layers  as  they  form  ;  the  old  layers  being  consumed  by  the 
normally  progressive  formation  of  medullary  cavities,  and  the  new 
remaining  soft,  the  bone  becomes  brittle."  '  It  seems,  hoAvever,  from  the 
experiments  of  Heitzmann,  that  this  opinion  should  be  modified,  at 
least  as  regards  rachitis  produced  by  lactic  acid.  Moreover,  in  rachitic 
craniotabes,  occurring  in  infancy,  there  is  certainly  bone  absorption, 
for  portions  of  the  occipital  and  parietal  bones  are  absorbed  to  cause 
the  soft  spaces.  We  must,  therefore,  believe  that  there  is  in  rachitis 
more  or  less  absorption  of  lime-salts  in  the  bone,  in  addition  to  that 
required  in  the  normal  growth  of  medullary  cavities  and  canals  for 
vessels. 

In  healthy  bone,  the  earthy  salts  are  in  excess  of  organic  matter, 
nearly  in  the  pro])ortion  of  two  to  one;  but  in  rachitis  the  proportion 
is  reversed,  the  organic  matter  being  much  in  excess.  The  following 
table  gives  analyses  of  rachitic  bones  by  Marchand,  Davy,  Boettger, 
and  Friedleben : 


I'cniiir. 

Kiul 

us. 

Vertel 

ir.T.. 

Inorganic 

Organic. 

Inorganic. 

Organic. 

Inorganic. 

Organic. 

Case      I. 
Ca.se    II. 
Casein. 
Case  IV. 

20  00 
37  80 
20.89 
52.85 

79.40 

62.20  (conval  ) 

79.11 

47.15 

21.24 
20.00 

78  70 
80.00 

18.68 
32.29 

81.32 
67.71 

*  Cellular  Pathology,  Chance's  Translation,  Lecture  xix. 


ANATOMICAL    CHARACTERS.  115 

As  might  be  expected,  the  rehxtive  proj^ortion  of  organic  and  in- 
organic matter  varies  greatly  in  different  cases,  and  at  different  stages 
of  the  same  case.  In  severe  rachitis  many  bones  are  affected.  It  is 
stated  that  there  is  no  bone  in  the  entire  skeleton  that  may  not  suffer, 
but  in  mild  cases  only  a  few  are  involved,  at  least  to  such  an  extent  as 
to  produce  structural  changes,  appreciable  to  touch  or  sight. 

Pathology  of  Rachitis. — In  this  connection,  it  is  proper  to  consider 
the  patJiolofjy  of  rachitis.  What  is  its  nature?  Niemeyer,  in  my 
opinion,  expresses  the  correct  vieAv,  when  he  says  "it  seems  to  me  that 
the  most  probable  hypothesis  regarding  the  cause  of  rachitis  is  that 
which  refers  it  to  inilammation  of  the  epiphyseal  cartilages  and  peri- 
osteum." The  increased  vascularity  of  the  periosteum,  the  prolifera- 
tion of  periosteum  and  cartilage,  the  tenderness  and  pain  on  motion, 
and  the  febrile  movement  -in  acute  forms  of  the  disease,  indicate  in- 
flammation rather  than  any  other  recognized  pathological  state.  The 
rachitic  inflannnation  as  it  affects  the  osseous  system,  appears  to  be  of 
a  chronic  or  subacute  character,  presenting  an  analogy  with  certain 
other  sveil-known  inflammations;  such  as  cirrhosis  and  certain  forms 
of  chronic  nephritis,  in  which  proliferation  or  connective  tissue  and 
sclerosis  occur.  The  eburnation  rather  than  normal  ossification,  which 
terminates  the  rachitic  process,  may  properly  be  considered  an  osteo- 
sclerosis. Comformably  with  the  theory  of  the  inflammatory  nature 
of  rachitis,  the  periosteum  is  found  infiltrated  and  thickened,  and  of  a 
reddish  hue  from  hyperoemia,  and  from  the  presence  of  the  ncAvly 
formed  capillaries  underneath,  which  have  been  described  above  as 
formiug  a  layer  of  considerable  thickness,  known  as  the  "germinal, 
vascular  tissue."  Moreover,  as  in  inflammation,  some  secretion  along 
with  the  vascular  growth  occurs  over  the  bone  from  the  under  surface 
of  the  periosteum.  The  various  interspaces  in  long,  short,  and  flat 
bones,  the  diploe,  cancclli,  and  interlamellar  openings,  contain  a  sub- 
stance similar  to  that  exuded  under  the  periosteum.  It  appears  to  be 
an  inflammatory  exudation. 

Anatomical  Characters  in  the  Stage  of  Deformity. — Rachitic 
bone,  when  the  disease  has  continued  for  some  time  and  is  still  in  its 
active  period,  presents  a  bluish  or  dusky-red  appearance,  from  its  in- 
creased vascularity.  After  a  variable  time,  weeks  or  months  according 
to  the  severity  of  the  disease,  deformities  begin  to  appear. 

Si)iegelberg's  descrij)tion  of  the  appearance  of  the  rachitic  foetus  cor- 
responds for  the  most  part  with  wliat  I  observed  in  the  one  whose  skeleton 
is  re[)resented  in  Fig.  (J.  A^ccording  to  this  writer,  the  body  and  limbs 
are  plump :  the  latter  short  and  curved ;  the  abdomen  large  and  promi- 
nent; and  the  head  sometimes  hydrocephalic.  The  skin  is  thick  and 
loose,  and  the  adipose  tissue  well  developed;  the  liver  large  ;  the  epi- 
physes swollen  and  soft ;  the  short  and  curved  diapliyses  sometimes 
broki'U.  The  rotundity  of  the  thorax  is  preserved,  and  the  sternum  is 
not  carried  forward,  since  tlu-re  has  been  no  respiration  ;  the  ribs,  in 
softness  and  liability  to  fracture,  correspond  witli  the  long  bones  of  the 
extremities.  The  sternum,  most  of  all  the  bones,  shows  the  delay  in 
ossification  ;  the  clavicle  is  among  those  least  aflected.     The  cranium 


116  RACHITIS. 

may  be  represented  by  a  meinl)ranous  bag  with  plaques  of  bone,  or  the 
cranial  bones  may  be  tbrmeil  and  in  shape,  but  thickened,  and  softened  ; 
tlie  sacral  ])romontory  is  pressed  forwai-d  and  downward  ;  the  sacral 
vertebrju  llattened  ;  the  ilia  flattened  and  widened,  and  the  pubic  arch 
increased. 

It  is  interesting  to  compare  these  deformities  with  those  in  the  child, 
since  they  occur  under  conditions  so  very  diflferent.  llachitic  bone 
seldom  retains  its  normal  form  or  shape;  its  pi-f»jecting  points  are 
rounded,  and  as  soon  as  it  softens,  it  begins  to  yield  to  })ressure  exerted 
upon  it.  Hence  the  curvatures,  so  connnon  and  characteristic.  The 
portion  of  a  long  bone  which  is  formed  after  rachitis  commences,  con- 
tains so  little  earthy  matter  that  it  bends  readily  in  its  fresh  state, 
either  by  muscular  action  or  by  the  Aveight  of  the  trunk,  "  in  the 
manner,"  says  Vogel,  "of  a  quill  or  willow  stick."  The  interior  of  the 
bone,  which  was  formed  before  rachitis  began,  and  which  contains 
nearly  or  quite  the  r.ormal  proportion  of  lime,  is  apt  to  break  instead 
of  bending,  but,  as  it  is  surrounded  on  all  sides  by  the  soft  tissue,  the 
fragments  are  not  displaced,  and  probably  do  not  crepitate.  So  scanty 
is  the  calcareous  deposition  in  typical  cases,  that,  says  Trousseau,  "the 
bones  ....  can  be  cut  with  a  knife  with  as  much  ease  as  a  carrot 
or  other  soft  root,"  and  the  dried  specimen  weighs  but  from  one-sixth 
to  one-eiii'hth  as  much  as  normal  bone.  One  writer  states  that  the 
dried  rachitic  bone  is  sometimes  so  porous,  from  the  small  amount  of 
lime  which  it  contains,  that  it  is  possible  to  respire  through  it,  as 
through  a  sponge. 

In  ordinary  cases,  the  bones  which  exhibit  most  strikingly  the  rachitic 
change,  and  which,  therefore,  should  be  carefully  examined  in  making 
the  diagnosis,  are  the  cranial  bones,  the  ribs,  and  the  radius — the  sternal 
ends  of  the  ribs,  and  the  lower  end  of  the  radius.  It  is  seldom  that 
these  bones  do  not  give  evidence  of  the  disease,  if  it  be  present,  and  in 
greater  degree  than  other  bones.  'I'hey  are  the  first  to  be  affected  to  an 
extent  that  is  ap})reciable  to  the  observer. 

C]n(ngei<  in  the  Cranial  Bones. — In  these  bones  interesting  and  im- 
portant alterations  occur.  Their  edges,  which  corres])()n(l  with  tlie  c\n- 
physeal  cartilages,  undergo  jjroliferation,  and  become  thickened  like  the 
latter.  This  thickening,  and  the  delayed  union  of  the  sutures,  produce 
grooves,  which  can  be  traced  by  the  fingers  between  the  bones,  and 
which  are  sometimes  appreciable  to  the  sight.  Rachitis  causes  some 
enlargement  of  the  cranium,  but  the  enlargement  seems  greater  than  it 
really  is,  on  account  of  the  retarded  growth  of  the  facial  bones.  In  a 
discussion  on  rachitis  in  the  London  Pathological  Society,  reported  in 
the  Lancet^  it  was  stated  that  in  seventeen  rachitic  children,  with  an 
average  age  of  4.72  years,  the  average  circumference  of  the  head  was 
21.22  inches,  while  in  the  same  number  Avho  were  non-rachitic,  and 
with  an  average  age  of  6.05  years,  the  average  circumference  was  19.95 
inches. 

The  retarded  ossification  is  manifested  not  only  in  the  open  sutures, 
but  also  in  the  large  size  and  patency  of  the  fontanelles,  Avhich  are  not 

1  Liincut,  1880,  vol.  ii.  p.  1017. 


AXATOMICAL    CHARACTERS.  117 

closed  till  long  after  the  usual  time.  The  anterior  fontanelle  should  be 
closed  between  the  fifteenth  and  twentieth  months,  but,  in  the  racliitic, 
it  remains  membranous  till  after  the  second  year,  even  into  the  third  or 
fourth  year.  Since  examination  of  the  anterior  fontanelle  is  important 
in.  determining  Avhether  or  not  rachitis  be  present,  it  should  be  borne  in 
mind  that,  in  the  normal  state,  this  space  increases  in  size  till  the 
seventh  month,  when  it  is  at  its  maximum,  and  that  after  the  ninth 
month  it  becomes  progressively  smaller. 

The  sliape  of  the  rachitic  head  varies.  In  general,  instead  of  its 
normal  rounded  form,  it  approaches  a  square  shape.  Another  t^'pe  is 
sometimes  observed  in  Avhich  there  is  no  marked  angularity,  but  in 
which  the  antero-posterior  diameter  is  enlarged.  In  the  square  head, 
the  forehead  projects,  and  both  the  frontal  and  joarietal  protuberances 
are  unusually  prominent.  'The  sutures  are  depressed  to  a  certain  extent, 
as  has  already  been  mentioned,  and  the  anterior,  lateral,  superior,  and 
posterior  surfaces  of  the  cranium  are  more  flattened  than  in  health.  The 
lambdoidal  suture,  which  should  close  by  the  fourth  month,  and  the 
sagittal,  which  should  close  by  the  end  of  the  first  year,  have  made 
little  progress  towards  union  Avhen  the  second  year  begins.  The  undue 
prominence  of  the  frontal  and  parietal  bosses  takes  its  origin  from  the 
exaggerated  proliferation  of  the  periosteal  or  fibrous  covering  of  the 
bones. 

Craniotabcs. — Thinning  of  the  cranial  bones  in  places  so  that  the 
brain  lacks  proper  protection,  has  long  been  noticed  in  the  examination 
of  rachitic  heads,  but  the  injury  that  results  to  the  infant  was  over- 
looked till  pointed  out  by  Dr.  Elsiisser.  Craniotabcs  occurs  for  the 
most  part  in  patients  under  the  age  of  one  year,  and  a  large  proportion 
are  under  eiglit  months.  Its  occurrence  in  the  ftctus,  as  shown  by  a 
case  published  in  the  Mew  York  Obstetrical  Journal  in  1870,  and  by 
Heitzraann's  case,  has  already  been  alluded  to.  The  factors  in  pro- 
ducing tliis  thinning  are  rachitic  softening  of  the  l)ones  and  pressure; 
pressure  of  the  l)niin  from  within  and  of  the  ])illow  from  witliout.  Con- 
se(juently,  the  portions  of  the  cranial  arch  in  which  the  thinning  occurs 
are  the  posterior  and  lateral,  the  occipital  bone  and  the  posterior  half 
of  the  parietal.  If  the  infant  lie  chiefly  on  one  side,  in  its  crib,  on  this 
side  the  craniotabcs  occurs,  Avhile  tliose  ])ortions  of  the  cranium  which 
are  not  pressed  upon,  as  the  frontal  bone,  exhibit  no  thinning.  The 
soft  s|)Ots  are  yielding  when  pressed  upon,  and  in  the  cadaver  they  are 
seen  to  be  translucent  when  held  to  the  light.  The  amount  of  absorp- 
tion varies  greatly  according  to  the  degree  of  rachitic  softening,  and 
tlie  amount  and  continuance  of  the  pressure.  There  may  be  in  some 
instances  sinqtle  depressions,  like  erosions  in  the  bone,  with  a.  contin- 
uous but  thin  bony  layer  remaining;  but  in  other  cases,  such  as  have 
been  particularly  examined  and  studied  by  ])hysicians,  the  bone  absorp- 
tion is  com])lete  over  areas  of  greater  or  less  extent,  so  that  the  peri- 
cranium and  dura  mater  are  in  contact.  In  examining  a  child  for 
craniotabcs,  it  should  be  borne  in  niiml  that  the  margins  of  the  bones, 
even  when  there  is  no  thinning,  but  thickening  from  the  cartihiginous 
prolifenition,  are  flexible  in  the  rachitic.  The  pressure  uiu>t  be  made 
in  a  direction  away  from  the  sutures,  to  ascertain  whether  craniotabcs 


118  RACHITIS. 

has  occurred.  The  pressure  shoukl  at  first  be  made  lightly  and  cau- 
tiously, with  the  fingers,  for  if  there  he  total  absence  of  bone,  unless  of 
very  little  extent,  deep  and  forcible  pressure  might  injure  the  brain, 
for  so  soft  and  delicate  an  organ,  covered  only  by  the  scalp  and  dura 
mater,  badly  tolerates  pressure.  If  the  first  examination  detect  no  soft 
place,  the  fingers  may  be  pressed  more  firmly  against  the  scalp,  when, 
if  the  bone  be  much  thinned,  so  that  there  is  only  a  small  layer  of  the 
lime-salts  underneath,  it  will  be  found  to  yield.  The  sensation  com- 
municated to  the  fingers,  when  there  is  an  open  space  in  the  cranium, 
and  the  dura  mater  and  scalp  are  in  contact,  has  been  likened  to  that 
experienced  when  pressing  upon  a  fully  distended  bladder.  At  a  meet- 
ing of  the  London  Pathological  Society,  reported  in  the  Lancet  for 
Novendjer  20,  18b0,  Dr.  Lees  presented  statistics  to  show  that  cranio- 
tabes  Avas  ©ne  of  the  lesions  of  inherited  syphilis  ;  but  whether  it  may 
result  from  syphilis  or  not,  the  evidence  that  there  is  a  cranial  softening 
which  is  strictly  rachitic,  apjjears,  from  repeated  observations,  to  be 
sufficient. 

Si/mptoms  of  Craniotabes. — As  craniotabes  gives  rise  to  peculiar 
symjjtoms  quite  distinct  from  those  of  the  general  i-achitic  disease,  tliey 
may  be  properly  considered  in  this  connection.  Craniotabes  usually 
occurs  during  the  first  year  of  infimcy,  and  most  frequently  prior  to 
the  tenth  month.  The  brain  at  this  age  is  soft  and  yielding,  since  it 
contains  a  large  percentage  of  water.  Unless  handled  with  care  at  an 
autopsy,  it  is  readily  lacerated,  and  moderate  pressure  upon  it  is  seen 
to  disturb  and  move  it  at  a  considcraljle  distance  from  the  point  of  con- 
tact. It  assists  to  a-  proper  understanding  of  the  symptoms  of  cranio- 
tabes to  recall  to  mind  the  fact,  Avell  known  to  surgeons,  that  slight 
depression  of  even  a  small  portion  of  the  skull  is  apt  to  produce  grave 
symptoms.  It  is  not  surprising,  therefore,  that  craniotabes,  when  there 
is  a  space  of  considerable  size  in  the  cranial  arch  destitute  of  bone,  is 
attended  by  S3nnptonis  due  to  the  mecluinical  effect  of  external  pressure, 
whenever  a  substance  less  yielding  than  the  brain  comes  in  contact  with 
the  unprotected  part. 

Since  pressure  from  the  pillow  without,  and  from  the  brain  within,  is 
believed  to  be  the  cause  of  the  absorption,  tlie  craniotabes  must  obviously 
occur  in  the  posterior  and  postero-lateral  portions  of  the  cranium. 
Corresponding  with  this  explanation  of  the  causation,  the  tliinning 
actually  occurs  in  the  occipital  and  posterior  portions  of  the  parietal 
bones,  while  the  anterior  halves  of  the  parietjil  bones,  and  the  frontal 
bones,  are  even  thicker  than  normal,  from  the  cartilaginous  and  perios- 
teal proliferation  occurring  along  the  sutures  and  on  the  surface  of  these 
bones,  as  already  described.  It  is  well  knoAvn  that  long-continued 
pressure  produces  absorption  of  calcareous  matter  even  more  readily 
than  of  soft  tissues,  as  is  shown  in  the  absorption  of  a  tooth  of  the  first 
set  by  the  growth  of  the  dental  pulp  of  the  second  set.  In  the  normal 
growth  of  the  skull,  constant  absorption  of  the  under  surface  of  the 
cranial  bones  is  going  on  to  make  room  for  the  enlarging  brain,  and 
Avhen  no  calcareous  deposition  occurs  upon  the  external  surface  to  com- 
pensate for  the  loss  within,  we  might  expect  even  a  greater  amount  of 
craniotabes  than  ordinarily  occurs. 


ANATOMICAL    CHARACTERS.  119 

Every  rachitic  infant  is  fretful,  but  one  with  craniotabes  is  especially 
so,  if  the  open  spaces  be  of  considerable  size.  If  it  lie  upon  the  pillow, 
in  its  accustomed  manner,  as  is  most  natural  for  it,  the  unprotected 
portion  of  the  brain  may  be  so  pressed  upon  by  the  weight  of  the  head, 
that  it  feels  uncomfortable.  It  does  not  have  quiet  sleep,  probably 
because  the  cerebral  circulation  and  functions  are  in  a  measure  dis- 
turbed ;  it  is  apt  to  awaken  readily  and  often,  and  frets  till  it  is  taken 
in  the  nurse's  arms.  Sometimes  it  instinctively  seeks  a  position  on  the 
edge  of  the  pillow,  with  the  face  downwards,  and  it  becomes  more  quiet 
when  resting  over  the  nurse's  shoulder  with  the  fxce  backward.  But 
if  fretfulness,  disturbed  sleep,  and  the  necessity  of  closer  attention  on 
the  part  of  the  mother  and  nurse  were  the  only  ill-eifects  of  craniotabes, 
it  would  possess  much  less  pathological  significance  than  pertains  to  it. 
Pressure  upon  so  delicate  Jind  important  an  organ  as  the  brain,  involves 
risks  and  produces  serious  s^nnptoms  in  proportion  to  its  degree.  Even 
a  slight  injury  of  the  skull  which  produces  depression,  though  it  may 
be  of  trifling  amount,  will  cause  serious  forms  of  nerv^ous  disorder.  So 
craniotabes  is  believed  to  sustain  a  causative  relation  in  certain  cases  to 
one  of  the  most  dangerous  of  the  neuroses,  namely,  Ian/ngiS7nus 
stridulus,  an  affection  which  is  also  designated  "internal  convulsions," 
"spasm  of  the  glottis,"  and  "  Kopp's  asthma,"  although  Kopp  was  not 
the  first  to  describe  and  recognize  the  malady.  The  etiology  of  this 
neurosis  has  not  been  fully  elucidated.  It  is  certain  that  a  large  pro- 
portion of  those  Avho  suffer  from  it  are  rachitic,  and  that  it  is  more 
common  and  severe  where  rachitis  is  prevalent,  as  in  England,  than 
where  it  is  rare,  as  in  the  rural  districts  of  America.  It  is  not  often 
the  cause  of  death  in  this  country,  and  the  fatal  cases  that  do  occur  are 
only  seen  in  cities,  whereas  in  parts  of  Euro[)e,  where  rachitis  is  much 
more  common  than  with  us,  it  causes  many  deaths. 

Certain  infants,  when  in  a  state  of  excitement,  have  what  are  termed 
"holding-l)reath  spells."  The  face  is  flushed,  and  breathing  ceases  for 
some  seconds,  after  which  respiration  returns  and  is  normal.  These 
attacks  are  unimportant,  but  they  appear  to  be  the  same  in  nature  with 
the  more  severe  and  dangerous  seizures  of  laryngismus  stridulus.  They 
have  no  pathological  significance,  excepting  as  they  show  the  same 
neuropathic  state  as  that  in  laryngismus,  and  as  they  maybe  precursors 
of  this  disease.  Laryngismus  stridulus,  or  glottic  spasm,  is  usually 
preceded  by  more  or  less  impairment  of  the  general  health,  and  often 
l)y  fretfulness,  which  is  characteristic  of  the  rachitic  state;  but  the 
attack  occurs  suddeidy,  without  premonition  and  is  of  short  duration. 
It  begins  with  an  arrest  of  respiration,  a  true  ai)n(ica,  as  if  from 
jtaralysis  of  the  respiratory  centre  in  the  medulla.  The  lips  may  be 
livid;  a  ))allor  spreads  over  the  face;  sometimes  more  or  less  rigidity 
of  the  limbs  occurs,  with  carpo-pedal  contractions,  and  after  a  few 
seconds,  a  (piarter  or  a  iialf  minute,  a  long  and  deep  but  dilfK  idt  inspi- 
ration through  the  narrow  chink  of  the  glottis  follows,  acc(jmpaiiied  in 
many  patients  by  a  whistling  or  crowing  sound,  and  the  attack  ends 
with,  jxM-haps,  a  momentary  look  of  bewilderment,  or  dread,  on  the 
child's  face.  Now  this  disease,  like  eclampsia,  doos  not  have  a  uniform 
causation.     In  certain  cases,  it  appears  to  be  a  reflex  phenomenon,  due 


120 


RACHITIS. 


to  an  irritant  in  some  part  of  the  system,  as  in  the  intestines ;  but 
many  observations  have  established  tlie  fact  that  rachitis,  also,  sustains 
a  causative  relation  to  it.  A  large  proportion  of  the  infants  aifected 
with  laryngismus  exhibit  unmistakable  rachitic  signs,  and,  in  the 
opinion  of  many  experienced  observers,  the  exposed  state  of  the  brain 
aifords  explanation  of  the  fact  that  so  many  of  the  rachitic  have  this 
neurosis.  Still  from  observations  which  I  have  made,  and  from  those 
of  other  observers,  like  Senator,  it  is  certain  that  laryngismus  stridulus 


Fig.  7. 


Head  of  a  rachitic  child  in  the  New  York  Infant  Asylum. 


is  common  in  the  rachitic  who  do  not  have  craniotabes,  so  that  there 
must  be  a  causative  relation  in  rachitis  to  laryngismus  independently  of 
the  cranial  softening.  The  accompanying  woodcut  represents  the  rachitic 
head  of  a  child  in  the  New  York  Infant  Asylum.  This  patient  had 
also  attacks  of  laryngismus  stridulus. 

Changes  in  the  Vertehrce,  etc. — The  short  bones  which  participate 
in  the  rachitic  disease,  become  softer  and  more  yielding,  and  their 
cancelli  are  filled  with  a  reddish  pulpy  substance.  In  many  rachitic 
cases,  the  vertebrae  are  but  slightly  involved,  so  that  no  deformity  of 
the  spinal  column  results ;  but  occasionally,  when  many  bones  are 
affected,  the  vertebn^  and  intervertebral  cartilages  soften,  and  spinal 
curvatures  result.  The  curvatures  are  due  to  the  Aveight  of  the  shoulders 
and  head  on  the  spinal  column.  They  are,  with  some  deviations,  an 
exaggeration  of  those  present  in  the  normal  state.  Rachitic  curvatures 
of  the  spine  are,  therefore,  mainly  an tero-posterior  with  some  lateral  deflec- 
tions. Where  there  is  much  curvature,  the  vertebroe  become  wedge- 
shaped,  narrowed  upon  the  concavity,  and  thickened  upon  the  convexity. 
The  intervertebral  cartilages  are  also  more  or  less  changed  by  the  press- 
ure, being  thinned  where  the  vertebrse  approximate  to  each  other,  on 
the  concave  aspect  of  the  curvature,  and  of  normal  thickness  or  thicker 


ANATOMICAL    CHARACTERS. 


121 


Fig.  8. 


than  normal  upon  the  convexity.  The  accompanying  woodcut  exhibits 
the  nature  and  appearance  of  rachitic  spinal  curvature  in  the  adult. 
Rachitis  having  occurred  at  the  usual  age,  resulted  in  the  permanent 
deformity  here  illustrated.  In  extreme  cases,  fortunately  rare,  the 
functions  of  important  organs  may  be  seriously  impaired  by  the  curva- 
ture and  consequent  compression,  as  in  Pott's  disease.  Thus,  according 
to  Miller,  the  aorta  has  been  so  doubled  upon 
itself  as  to  diminish  materially  the  flow  of 
blood  to  the  lower  extremities,  and  sensibly 
impair  their  nutrition.  The  effect  of  so 
great  curvature  upon  the  functions  of  the 
heart  and  lungs  must  obviously  be  detri- 
mental. 

At  first  the  spinal  curvatures  disappear 
when  the  child  reclines,  or  is  lifted  by  the 
axilk^,  so  as  to  raise  the  head  and  shoulders 
from  the  spine,  but  Avhen  the  deformity  has 
continued  so  lono;  that  the  vertebrae  and  car- 
tilages  have  become  wedge-shaped,  it  remains 
for  life,  or  can  only  be  rectified  slowly  and 
with  diffculty  by  mechanical  appliances.  As 
seen  in  the  woodcut,  the  common  curvature 
in  the  dorsal  region  is  backward  [kyphosis), 
while  to  compensate  the  patient  instinctively 
carries  the  neck  forward,  with  the  head 
thrown  back,  causing  cervical  lordosis,  a 
simihir  anterior  curvature  being  common  in 
the  lumbar  region.  Lateral  curvature  (sco- 
liosis) may  or  may  not  be  present,  even  when 
there  is  considerable  antero-posterior  flexure. 
Scoliosis  is  sometimes  produced  by  the  nurse, 
in  carrying  the  infant  habitually  over  one  arm. 

Chanf/cs  in  the  Maxilla'. — Fleisclimann  has  investigated  the  changes 
which  rachitis  produces  in  the  maxillary  bones.  Stunted  growth  of  the 
facial  bones,  generally,  has  long  been  known,  and  has  been  remarked 
upon  by  various  writers;  but,  according  to  Fleisclimann,  other  interest- 
ing changes  occur  in  the  jaw-bones,  which  affect  the  direction  and 
position  of  the  teeth.  According  to  tliis  author,  tlic  arched  shape  of 
the  lower  jaw  becomes  polygonal,  and  the  directiftn  of  the  alveolar  pro- 
cess also  chan-^es,  so  that  it  inclines  inward.  This  deviation  in  the  arch, 
and  in  the  alveolar  process,  which  begins  in  the  region  of  the  canine 
teeth,  necessarily  causes  shortening  of  the  lower  jaw.  Commencing 
soon  after,  a  change  is  observed  in  the  upper  jaw-bone  from  tlie  zygo- 
matic arcli  forward,  so  as  to  cause  lengtliening  of  this  bone,  changing 
here  iilso  the  shape  of  the  arch  and  the  |)osition  of  the  teeth.  The 
lateral  incisors,  instead  of  l)eing  in  front,  have  a  lateral  position,  and 
the  incisors  and  molars  diverge,  so  that  when  the  jaws  are  closed  they 
overlap  the  corresponding  teeth  of  the  lower  jaw  in  front  and  upon  the 
Bides,  a  condition  the  ojiposite  of  that  seen  in  the  jaws  of  old  people. 
Fleischmanu  attributes  these  changes  in  the  lower  jaw  to  the  action  of 


Eachitic  spinal  curvature  in  an 
adult.  (From  a  spuciuieu  in  the 
Wood  Museum,  Bellevue  Ilospital.) 


122 


RACHITIS. 


the  masseter  and  mylo-hyoid  muscles,  and  perhaps  the  ^enio-glossus, 
and  to  pressure  of  the  lip,  the  deficiency  of  earthy  salts  in  the  bone 
rendering  it  more  easily  acted  on  by  the  muscles.  The  change  in  the 
upper  jaw-bone  he  attributes  to  lateral  pressure  of  the  zygomatic  arches. 

Cha)iges  in  the  Ribs. — The  ribs  are  early  affected  in  rachitis.  The 
swelling  of  their  anterior  ends,  where  they  unite  with  the  costal  carti- 
lages, producing  the  "  rachitic  rosary,"  has  been  already  alluded  to  as 
one  of  the  first  and  most  conspicuous  signs  of  rachitis.  The  costo- 
chondral  articulations  are  enlarged  in  all  directions,  appearing  as  nodules 
under  the  skin.  If  an  opportunity  occur  of  inspecting,  at  an  autopsy, 
the  pleural  surface,  the  nodular  prominences  are  seen  to  be  even  greater 
and  more  distinct  there  than  under  the  skin. 

The  deformity  of  the  thorax  consequent  upon  softening  of  the  ribs  is 
interesting.     Commencing  with  the  spine,  the  ribs  extend  nearly  di- 


FiG.  9. 


Bachitjc  child  with  characteristic  defurmity  of  head,  ribs,  and  rading. 

Yuik  Fouudliug  Asylum  ) 


(From  a  patient  in  the  Kow 


rectly  outward  ;  at  the  union  of  the  dorsal  and  lateral  regions,  they  make 
a  short  curve  forward,  and  then  turn  inward,  also  with  a  short  curve 
toward  the  sternum  (Fig.  10).  This  abrupt  bending  of  the  ribs,  which, 
in  their  softened  state,  has  been  caused  by  atmospheric  pressure  during 
respiration,  produces  a  depression  in  the  thoracic  wall  at  about  the 
point  where  the  ribs  and  their  cartilages  unite.  A  groove  extends  on 
the  antero-lateral  surface  of  the  thorax  from  the  second  or  third  rib 
downward,  and  a  little  outward.  Sometimes  the  bottom  of  the  groove 
is  occupied  by  the  costo-chondral  joints ;  in  other  cases  these  joints  are 
a  little  to  one  side  of  the  deepest  part  of  the  groove.  The  transverse 
diameter,  therefore,  of  the  anterior  half  of  the  thorax  is  much  less  than 
in  health.     This  necessarily  diminishes  the  lateral  expansion  of  the 


A  X  A  T  O  :M  I C  A  L    CHARACTERS 


123 


lung  in  inspiration,  and  causes  unusual  prominence  of  the  sternum. 
Hence  the  expressions  "  pigeon-breasted,"  "  resemblance  to  the  prow 
of  a  ship,"  etc.,  applied  to  this  deformity.  The  presence  of  the  heart 
renders  the  groove  more  shallow  on  the  left  side,  at  the  fourth  and  fifth 
ribs,  than  on  the  opposite  side,  since  this  organ  affords  partial  support 
to  the  chest- wall.  On  the  other  hand,  the  right  groove  is  not  as  long 
as  the  left,  as  the  lower  ribs  on  this  side  are  partially  supported  by  the 
liver.  On  both  sides,  however,  the  lower  part  of  the  thorax,  that  below 
the  seventh,  eighth,  or  ninth  ribs,  widens,  being  pressed  outward  and 
supported  by  the  abdominal  viscera.  There  is,  therefore,  in  addition 
to  the  longitudinal  groove,  an  antero-posterior  depression,  sometimes 
also  spoken  of  as  a  furrow  or  groove,  on  either  side,  lying  between  the 
sixth  and  ninth  ribs. 

The  ribs  with  their  attached  muscles  are  important  agents  in  respira- 
tion, but  the  soft  and  yielding  nature  of  the  ribs,  in  the  rachitic,  retards, 


Fir..   10. 


Deformity  of  cbest  in  rachitis. 


and  to  a  great  extent  prevents,  the  lateral  ex})ansion  of  the  thorax  which 
is  necessary  for  normal  and  full  inspiration.  The  action  of  the  respira- 
tory muscles,  and  the  pressure  from  within  of  the  air  descending  along 
the  air  passages,  is  not  sufficient  to  overcome  fully  the  external  atmos- 
pheric pressure,  in  the  absence  of  proper  resiliency  of  the  ribs.  Con- 
senuently,  with  each  inspiration,  we  observe  more  or  less  sinking  in  of 
the  thorax  on  either  side,  just  as  when  a  moderate  obstruction  to  the 
entrance  of  air  exists  in  the  larynx  or  trachea.     As  the  ribs  become 


124 


RACHITIS. 


firmer  from  the  deposit  of  lime-salts,  respiration  is  more  regular  and 
normal. 

Clianges  in  Bones  of  U2:>per  Extremity. — Although  swelling  of  the 
lower  end  of  the  radius  (see  Fig.  9)  is  one  of  the  earliest  signs  of 
rachitis,  the  bones  of  the  upper  extremities  are  less  frequently  curved 
and  distorted  than  those  of  the  lower  extremities.  The  clavicle  some- 
times softens  and  bends,  producing  two  curvatures,  one  backward,  near 
the  scapula,  and  another  of  larger  size  nearer  the  sternum,  directed 
forward  and  a  little  upward.  Careful  examination  shows,  in  some 
rachitic  patients,  thickening  of  the  margins  of  the  scajiula,  like  that  of 
the  cranial  bones.  The  humerus  is  occasionally  bent,  and  usually  at 
the  point  of  insertion  of  the  deltoid,  in  consequence  of  the  powerful 
action  of  this  muscle  in  raising  and  supporting  the  arm.  The  radius 
and  ulna  are  bent  outward  and  twisted.  The  deformity  is  attributed 
by  Sir.  William  Jenner  to  the  fact  that  ricketty  children  support  them- 
selves, while  in  the  sitting  posture,  upon  the  palms  of  the  hands  pressed 
upon  the  floor  or  couch.  Supporting  the  weight  of  the  body  in  this 
way  not  only,  in. his  opinion,  causes  bending  of  the  ulna  and  radius,  but 
also  aids  in  producing  the  deformities  of  the  humerus  and  clavicle. 

Clianges  in  Bones  of  Pelvis. — The  deformities  of  the  pelvic  bones, 
resulting  from  rachitic  softening,  are,  in  the  female  infant,  the  most  im- 
portant of  any  which  the  skeleton  undergoes.     They  are  produced  by 


Fig.  11. 


Fig.  12. 


Fig.  13. 


Bachitic  deformities  of  the  jielvis.     (From  specimens  in  tlie  AVood  Museum.) 

pressure  from  above  of  the  abdominal  organs,  serving  to  witlen  the  brim 
of  the  pelvis,  and  also  by  pressure  of  the  spinal  column,  sustaining  the 
weight  of  the  trunk,  shoulders,  and  head,  pressing  forwards  the  pro- 
montory of  the  sacrum,  in  the  sitting  posture,  and  thus  diminishing  the 
antero-posterior  diameter  of  the  pelvic  brim.  There  is,  moreover,  two- 
fold pressure  from  below,  that  caused  by  the  heads  of  the  thigh-bones, 
in  standing,  and  that  exercised  by  the  tuberosities  of  the  ischia,  in  sit- 
ting. Both  these  forms  of  pressure  have  a  tendency  to  narrow  the  out- 
let of  the  pelvis.  Hence  the  marriage  of  the  female  wiio  has  been 
rachitic  in  infancy  may  involve  serious  consequences.     Many  of  the 


ANATOMICAL    CHARACTERS. 


125 


tedious  instrumental  labors  in  the  fiimilies  of  the  city  poor,  -which 
severely  tax  the  patience  and  endurance  of  young  practitioners,  are  at- 
tributable to  rickets  in  early  life. 

Changes  in  Bones  of  Loiver  Extremities. — The  curvature  of  the 
femur  is  usually  forward,  or  forAvard  and  outward.  The  neck  of  the 
femur  sometimes  bends  by  the  weight  of  the  body,  or  by  use  of  the  legs, 
so  tliat  the  angle  which  it  forms  with  the  shaft  is  changed.  The  an- 
nexed woodcuts  show  the  rachitic  bend  of  this  bone  in  an  adult,  years 
after  rachitis  had  ceased,  and  Avhen  the  bone  had  become  consolidated 
by  the  new  deposition  of  lime-salts. 

"  The  curvature  of  the  tihia  and  fibula  varies.     In  those  under  the  age 
of  one  year,  it  is  apt  to  be  outward,  so  that  the  knees  are  separated  from 


Fig.  14. 


Fig.  15. 


Rachitic  deformities  of  the  femur      (AVood  Museum.) 


each  other.  In  those  old  enough  to  stand,  the  weight  of  the  body 
usually  determines  a  forward  bending  of  these  bones.  In  one  case  in 
my  practice,  an  anterior  curvature  so  abrupt  that  an  angle  of  about  TO'^ 
was  formed,  existed  about  four  inches  above  each  ankle.  This  patient, 
though  old  enough  to  walk,  almost  constantly  sat  during  the  day  with 
the  feet  extended  beyond  the  sofa,  so  tliat  the  edge  of  the  latter  corre- 
sponded with  the  concavity  of  the  legs.  It  seemed  to  me  that  the 
weight  of  the  feet  must  have  been  a  factor  in  causing  these  curvatures, 
especially  as  the  case  was  one  of  very  marked  rachitic  softening  of 
different  bones.  Still,  tibial  and  fibular  bending  at  this  point  has  been 
noticed  by  different  observers,  who  have  attributed  it  to  the  weight  of 
the  body  in  walking.  Various  other  curvatures,  besides  those  men- 
tioned, occur  in  the  bonc^  of  the  lower  extremities,  the  direction  in 
which  the  limbs  bend  being  determined  by  the  particular  circumstances 
of  the  case. 

In  mild  ca.ses  of  rickets,  most  of  the  deformities  described  above  are 
lacking,  but  in  typical  cases  certain  of  them  stand  out  prominently,  so 
as  to  be  readily  detected  by  one  familiar  with  the  disease.  In  all  such 
cases  the  diagnosis  is  easy  beyond  that  of  most  other  maladies,  for  the 
changes  which  occur  are  not  only  conspicuous,  but  pathognomonic. 

l{achitis  produces  another  important  effect  on  the  skeleton.  Its 
growth  is  stunted,  not  only  during  the  rachitic  period,  but  subse- 
(juently,  so  that  those  who  have  been  rachitic  in  childhood,  unless  very 
mildlv,  have  less  than  the  averafje  stature  in  adult  life.  The  stunted 
growth  is  apparent,  though  ample  allowance  be  made  for  curvatures. 
The  arrest  of  development  is  greater  in  some  bones  than  in  others.  It 
is  greatest  in  the  bones  of  the  face,   pelvis,  and  lower  extremities. 


126 


RACHITIS. 


Stunted  growth  of  the  pelvic  bones  of  the  female  infant  conjoined  with 
the  deformities  alluded  to  above,  may  seriously  affect  her  subsequent 
life,  and  a  rachitic  pelvis  in  the  female,  exhibiting  both  stunted  growth 
and  deformity,  constitutes  a  valid  reason  for  avoiding  marriage.     As  a 


Fig.  16. 


Fig. 


Rachitic  deformities  of  the  femur,  tfhin,  and  fibula     (Wood  Museum.) 

rule,  the  older  the  child  is  when  rachitis  begins,  the  less  is  the  skeleton 
affected,  and  the  less  consequently  is  the  deformity. 

Effect  of  Racliitis  on  Dentition. — As  might  be  expected  from  the 
nature  of  rachitis,  dentition  is  delayed.  If  the  disease  show  itself 
before  any  tooth  has  appeared,  the  first  teeth,  to  wit,  the  lower  central 
incisors,  will  probably  not  appear  before  the  ninth  or  tenth  month,  or 
even  later.  Sir  Wm.  Jenner  considers  the  non-appearance  of  a  tooth 
by  the  ninth  month,  with  few  exceptions,  a  sign  of  rachitis.  Teeth 
which  appear  during  the  rachitic  state  are  frail,  deficient  in  enamel, 
and  crumble  readily.  They  become  carious,  rot,  and  break  before  the 
usual  time.  If  certain  teeth  have  appeared  when  rachitis  begins, 
several  months  elapse  before  others  cut  the  gum.  It  is  even  said  that  a 
child  who  has  rachitis  severely  may  never  have  a  tooth,  may  remain 
toothless  for  life ;  but  I  have  never  observed  such  a  case.  Ordinarily, 
when  the  rachitic  state  ceases,  and  the  health  is  fully  restored,  dentition 
goes  on  as  before.  The  arrest  of  teething,  so  easily  observed,  has  long 
been  considered  one  of  the  most  reliable  diagnostic  signs.  The  physi- 
cian cannot  justly  pronounce  on  the  nature  of  the  disease  in  a  case  of 
suspected  rachitis,  unless  he  first  carefully  inspects  the  gums. 


ANATOMICAL    CHARACTERS.  127 

Changes  in  the  Soft  Tissues. — Although  the  conspicuous  lesions  of 
rickets  pertain  to  the  skeleton,  the  soft  tissues  are  also  more  or  less 
implicated.  The  ligaments  become  relaxed  and  flabby,  giving  unusual 
mobility  to  the  joints,  and  unsteadiness  to  the  movements.  The  fibrous 
bands  which  unite  the  vertebra,  as  well  as  the  ligaments  of  the  ex- 
tremities, participate  in  the  relaxation.  In  certain  patients,  the  muscles 
throughout  the  system,  partly,  perhaps,  in  consequence  of  the  gastro- 
intestinal disturbance,  indigestion,  and  malnutrition ;  partly,  perhaps, 
from  want  of  use  (for  the  rachitic  are  apt  to  be  quiet),  become  shrunken 
and  flabby.  The  spleen  is  frequently  enlarged,  as  ascertained  by  pal- 
pation and  percussion.  Ritter  von  Rittershain  found  this  organ  deci- 
dedly enlarged  in  ten  out  of  thirty-five  cases  which  he  examined  after 
death.  The  enlargement  is  the  result  of  cellular  proliferation,  common 
in  diseases  which  are  attended  by  dyscrasia.  The  liver  in  many  patients 
undergoes  no  perceptible  change,  except  that  it  may  be  pushed  a  little 
downwards.  It  is  occasionally  found  enlarged  from  fatty  infiltration, 
but  no  special  significance  attaches  to  this,  for  fatty  liver  is  common  in 
various  forms  of  disease  attended  by  innutrition  and  Avasting.  It  is 
common  in  tuberculosis,  and  in  protracted  intestinal  catarrh,  and  its 
pathological  significance  appears  to  be  the  same  in  these  various  diseases. 
There  can  be  little  doubt  that  Sir  Wm.  Jenner  errs  when  he  states  that 
albuminoid  infiltration  of  the  liver  is  common  in  rachitis.  Parry,  Gee, 
Dickinson,  and  Senator  agree  that  it  is  rare,  and  that  if  it  does  occur, 
it  is  by  coincidence. 

In  a  discussion  on  rachitis,  in  the  London  Pathological  Society,  Dr. 
Dickinson '  spoke  of  enlargement  of  the  spleen,  liver,  and  lymphatic 
glands,  which  he  had  observed  in  rachitic  cases.  According  to  him, 
the  spleen  undergoes  the  greatest  enlargement,  the  lymphatic  glands 
the  least,  and,  of  the  latter,  "the  mesenteric  glands  show  the  most 
decided  swelling."  The  spleen  in  some  patients  has  been  so  large  that 
it  occupied  the  greater  part  of  tlie  left  half  of  the  abdominal  cavity,  but  a 
less  degree  of  enlargement  is  the  rule.  The  liver  is  apt  to  extend  one  or 
two  inches  below  the  ribs.  The  swelling,  Dr.  Dickinson  adds,  is  not 
amyloid.  "  There  is  no  new  growth  or  deposit,  only  an  irregular 
development  of  the  proper  tissues  of  the  organs."  He  believes  that 
both  the  corpuscular  and  interstitial  elements  are  increased  in  the  liver, 
spleen,  and  lymphatic  glands.  But  other  members  of  the  Society  had 
observed  this  enlargement  only  in  occasional  cases,  and  they  considered 
it  due  rather  to  the  state  of  healtli  which  caused  rachitis  than  to  rachitis 
itself.  Dr.  C.  Hilton  Fagge  stated  that  he  had  fiiiled  to  find  swelling 
of  the  liver,  spleen,  or  lymphatic  glands,  in  a  large  majority  of  cases.^ 
An  undue  develo))ment  of  the  lymphatic  glands  from  hyperplasia  is  very 
common  in  children  in  various  states  of  ill-health,  ami  the  mesenteric 
glands  are  especially  apt  to  become  enlarged  from  this  cause  in  protracted 
cases  of  intestinal  catarrh  or  irritation. 

The  abdomen  is  protuherant  from  various  causes.  The  lateral 
depression  of  the  thoracic  walls  causes  the  liver  and  sjileen  to  descend 
a  little  lower  in  the  abdominal  cavity  than  natural.     The  enlargement 

>  Lnncet,  December  11,  1880.  «  Lancet,  November,  20,  1880. 


128  RACHITIS. 

of  the  liver  and  spleen,  the  feeble  tonicity  of  the  intestinal  muscular 
fibres,  and  consequent  distention  of  the  intestines  with  gas,  and  the 
racliitic  shortening  of  the  spinal  column,  which  causes  approximation 
of  the  ribs  and  pelvis,  necessarily  produce  abdominal  protuberance. 

The  kidneys  themselves  are  not  diseased  in  rickets,  but  there  is  an 
exaggerated  discharge  of  phosphates  in  tlie  urine,  and,  as  stated  above, 
lactic  acid  and  free  phosphoric  acid  have  been  found  in  this  excretion. 
The  urine  is  commonly  pale ;  its  urea  and  uric  acid  are  diminished; 
and  it  sometimes  contains  a  sediment  of  oxalate  of  lime. 

The  brain  is  usually  well  developed,  and  appears  healthy,  with  the 
normal  proportion  of  white  and  gray  substance.  In  one  case  the  weight 
of  this  organ  was  ascertained  by  Dr.  Gee  to  be  fifty-nine  ounces,  and 
in  another  forty-two  and  a  half  ounces.  In  both  brains  the  proportion 
of  white  and  gray  substances,  and  their  color  and  consistence,  seemed 
normal. 

Anatomical  Characters  of  the  Third  Stage,  or  that  of 
Reconstruction. — This  stage  will  be  better  understood,  if  we  recollect 
what  has  occurred  during  the  first  and  second  stages.  The  very 
vascular  periosteum  is  drawn  tightly  over  convexities,  the  pressure  upon 
which  diminishes  the  hyperaemia  and  the  amount  of  exudation  under- 
neath. Over  the  concavities  the  periosteum  is  loose ;  it  is  hyperasmic, 
Avith  abundant  new  capillaries,  the  interspace  between  it  and  the  bone 
being  filled  with  the  gelatiniform  substance  already  described.  The 
reparative  process  goes  forward  more  rapidly,  and  the  deposition  of 
lime-salts  is  more  abundant  upon  the  concave  surfiices,  where  there  have 
been  free  exudation  and  no  compression  of  the  capillaries,  than  elsewhere. 
The  lime-salts  are  deposited  from  the  blood.  Consequently,  from  the 
increased  capillary  circulation  and  hypersemic  state  of  the  periosteum 
produced  by  rachitis,  the  chalky  matter  is  rapidly  effused  wherever 
there  is  an  open  space  under  the  periosteum,  and  where  the  capillaries 
are  in  a  state  of  engorgement.  Hence  the  reconstructed  bone  is  thicker 
and  firmer  upon  the  concave  aspect  of  the  long  bones  than  elsewhere, 
and  thinnest  upon  the  convex  aspect  where  the  periosteum  is  more 
tense,  and  its  capillaries  more  or  less  compressed. 

It  is  a  question  whether  true  ossification  occurs  at  first  during  the 
reparative  stage.  The  deposition  of  chalky  matter  is  designated  by 
some  writers  as  a  petrifaction  rather  than  a  true  bone-formation. 
Trousseau  likens  it  to  the  formation  of  callus  after  a  fracture.  It  cer- 
tainly produces  a  substance  more  compact  than  ordinary  bone.  The 
terra  "  eburnation  "  has  been  applied  to  this  new  osseous  formation,  and 
I  have  designated  it  "  osteo-sclerosis."  Some  years  since  I  examined 
microscopically  an  adult  bone  which  exhibited  the  rachitic  curvature  in 
a  marked  degree,  and  was  very  hard.  It  contained  the  elements  of 
true  bone,  but  I  was  in  doubt  whether  the  part  examined  was  formed 
during  convalescence  from  rickets,  or  in  the  subsequent  growth. 

Recovery  from  rickets  is  gradual.  Little  by  little,  the  cartilaginous 
and  periosteal  proliferation  ceases,  the  hyperaemia  abates,  and  the  bone- 
producing  tissues  return  to  their  normal  state.  Certain  of  the  defor- 
mities are  permanent,  but  others  disappear  in  the  further  growth  of  the 
skeleton. 


sy:NrPTOMs.  129 


Symptoms  of  Rachitis. 


Preceding  and  accompanying  rachitis,  symptoms  may  be  present 
which  are  due  to  indigestion  and  intestinal  catarrh,  such  as  flatulence, 
unhealthy  stools,  and  poor  or  capricious  appetite.  When  rachitis 
begins,  the  infant  becomes  fretful ;  its  sleep  is  apt  to  be  restless  and 
disturbed,  and  it  awakens  often.  It  repels  attempts  to  amuse  it,  and  is 
apparently  annoyed  by  them.  Nurse  and  mother  speak  of  it  as  a  cross 
child.  It  perspires  freely  from  the  head  and  neck,  both  when  awake 
and  when  asleep,  while  the  extremities  and  trunk  are  dry.  Its  pillow 
is  wet  with  perspiration  during  sleep,  and  sAveat  drops  may  be  seen  upon 
forehead  and  face.  If  the  surface  be  dry,  a  little  excitement  or  eleva- 
tion of  temperature  causes  .the  perspiration  to  appear.  The  r'achitic 
child  does  not  avcU  tolerate  the  bedclothes,  and  attempts  to  throw  them 
off  from  its  limbs,  even  in  cool  weather,  lying  exposed,  and  causing 
considerable  annoyance  to  the  nurse,  who  strives  to  prevent  its  taking 
cold.  Sometimes  miliaria,  due  to  the  moist  state  of  the  skin,  appear 
upon  the  face  and  neck.  The  subcutaneous  veins  which  return  blood 
from  the  head  are  large,  and  the  jugular  veins  full. 

Another  symptom  is  soon  observed,  to  wit,  tenderness  over  a  con- 
siderable part  of  the  surface,  perhaps  largely  due  to  the  morbid  state 
of  tiie  periosteum  over  so  many  bones,  though  it  is  also  experienced 
when  pressure  is  made  upon  the  soft  parts  of  the  abdomen.  The  ten- 
derness is  probably,  in  part,  the  cause  of  the  fretful  disposition.  The 
little  patient  appears  to  dread  to  be  touched  ;  its  flesh  is  sore ;  it  repels 
attempts  to  amuse  it,  and  wishes  to  be  quiet.  Dandling  it  upon  the 
arms,  swinging  it,  or  even  walking  with  it,  which  delights  the  healthy 
child,  and  elicits  a  smile  or  notes  of  glee,  only  adds  to  its  discomfort. 
It  is  most  at  ease  Avhen  left  alone,  upon  a  soft  cot  or  pillow,  or,  if  it 
have  craniotabes,  when  quietly  held  over  the  shoulder.  Languor,  dis- 
inclination to  use  the  limbs,  or  to  play,  moderate  thirst,  with  other 
symptoms  referable  to  the  digestive  apparatus,  which  are  present  in 
many  cases,  and  which  have  already  been  described,  are  soon  followed 
by  changes  in  the  skeleton,  which  arc  perceptible  to  the  sight  and  on 
palpation.  The  pulse  and  temperature,  in  a  large  proportion  of  the 
ordinary  chronic  cases,  do  not  deviate  from  the  healthy  state,  except 
that  in  some  patients  there  is  a  slight  febrile  movement  in  the  latter 
part  of  the  day. 

Although  rachitis  is  ordinarily  a  chronic  disease,  insidious  in  its 
commencement,  gradual  and  progressive  in  its  development,  occupving 
months,  there  is  an  acute  f«jrm  which  is  attended  by  more  niarke<l  febrile 
movement  and  tenderness,  and  in  which  the  articular  swelling  appears 
more  quickly. 

A  bruit  de  soujjfcf,  of  greater  or  less  intensity,  synchronous  with  the 
pulse,  has  frequently  been  heard  in  rachitic  cases  by  applying  the  ear 
over  the  anterior  fontanelle,  Drs.  Whitney  and  Fischer,  New  England 
physicians,  first  called  attention  to  this  murmur,  believing  it  to  be  a 
sign  of  chrcjnic  hydroce})halus.  MM.  Jiilliet  and  IJarthez  heard  it  in 
cases  of  rachitis,  and,  therefore,  concluded  that  the  American  physicians 

9 


180  RAGiriTIS. 

had  confounded  the  two  diseases.  More  recent  ohservations  have 
established  the  fact  that  this  hrait  has  little  diagnostic  value.  It  is 
heard  Avdienever  there  is  sufficient  patency  of  the  anterior  fontanelle, 
both  in  health  and  disease,  for  sound  is  conducted  better  through  a 
meuibrane  than  through  bone.  Dr.  Wirthgen  heard  the  bruit  in  22 
out  of  52  children,  of  whom  all  except  four  Avere  in  good  health.  I 
have  auscultated  the  anterior  fontanelle  in  29  infants,  who  were  with 
tAvo  exceptions  between  the  ages  of  three  and  thirty  months.  All  Avere 
Avcll,  or  having  merely  trivial  ailments  Avhich  did  not  affect  the  cerebral 
circulation.  In  most  of  them  a  murmur  could  be  distinctly  heard, 
synchronous  Avith  the  resj)iratory  act,  and  in  15  of  the  29  cases  no 
other  sound  could  be  detected,  Avhile  in  the  remaining  14  a  bruit  could 
be  detected,  synchronous  Avith  the  pulse. 


Complications  and  Sequelae  of  Rachitis. 

These  have  been  in  part  described  in  the  foregoing  pages,  out  there 
are  certain  other  results  of  the  disease  to  Avhich  it  is  proper  to  call  atten- 
tion. If  the  deformity  in  the  thoracic  Avail,  namely,  the  lateral  depres- 
sion of  the  ribs  and  anterior  projection  of  the  sternum,  be  great,  Ave 
Avould  naturally  expect  that  the  two  important  organs  underneath,  the 
heart  and  lungs,  Avould  receive  some  detriment.  Upon  the  surface  of  the 
heart,  at  the  point  where  it  supports  the  softened  ribs,  a  Avhite  patch  is 
often  found,  due  to  thickening  of  the  pericardium  and  proliferation  of 
the  endothelial  cells,  just  as  thickening  of  the  skin  in  the  palm  of  the 
hand  occurs  fi'om  friction  and  pressure  uj)on  that  part.  It  is  ])r()bable 
that  this  ])ressure  docs  not  seriously  impair  the  function  of  the  heart, 
but  it  may  increase  the  Aveaknoss  of  its  movements  in  any  asthenic  dis- 
ease Avhich  may  occur  during  the  rachitic  period.  The  injury  sustained 
by  the  lungs  is  greater  and  more  a])parent.  If  the  ribs  be  flexible, 
and  much  depressed,  full  inflation  of  the  lung  cannot  occur  in  those 
parts  Avhere  the  depression  is  greatest.  Semi-collapse  of  certain  lobules 
is  apt  to  occur,  and  even  com])lete  collapse  of  the  thin  edges  of  the  lung. 
The  stress  of  respiration  falls  inie(pially  upon  different  parts  of  the 
lung.  The  anterior  portion,  Avhich  ascends  Avith  the  sternum  as  that  is 
propelled  forward,  is  more  fully  dilated  than  the  lateral  and  posterior 
parts,  and  hence  is  apt  to  become  emphysematous.  If  in  this  state  of 
the  thorax  and  lungs,  severe  l)ronchitis  or  broncho-])ncumonia  arise,  the 
state  is  one  of  great  peril.  The  mucus  and  pus  being  expectorated  Avith 
difficulty,  clog  the  tubes  and  produce  dys])nt)ea.  Full  inspii-ation  in  the 
lateral  and  depending  portions  of  the  lung,  Avhich  is  required  m  order 
to  expel  these  secretions,  not  occurring,  the  result  may  be  unfavorable, 
even  in  comparatively  mild  forms  of  inflammation.  Bronchitis  and 
broncho-pneumonia  are  the  causes  of  death  in  not  a  few  cases  of  severe 
rickets.  Certain  Avriters  state  that  chronic  hydrocepltalus,  (liarrlioca^ 
and  eclampsia  may  complicate  rachitis.  I  have  not  seen  any  case  in 
Avhich  rickets  seemed  to  sustain  a  causative  relation  to  either  hydroce- 
phalus or  diarrhoea,  but  Ave  knoAV  that  diarrhoea  frequently  precedes  and 
accompanies  rachitis,  and  its  relation  to  it  is  that  of  cause  rather  than 


DIAGNOSIS.  131 


effect.  This  subject  has  been  sufficiently  treated  of  in  preceding  pages. 
llachitic  infants  appear  to  be  more  liable  to  eclampsia  than  those  AA'ho 
are  healthy.  This  would  be  inferred  from  their  liability  to  laryngismus 
stridulus,  a  neurosis  Avhose  pathology  is  similar  to  that  of  eclampsia. 


Diagnosis  of  Rachitis. 

Rachitis  in  many  instances  continues  a  considerable  time  before  its 
nature  is  suspected,  the  symptoms  to  Avhich  it  gives  rise  being  over- 
looked, or  attributed  to  other  causes  than  the  true  one;  and  yet  it  is 
important  that  an  early  diagnosis  be  made,  for  it  is  much  more  amen- 
able to  treatment  in  its  early  than  in  its  later  stages.  The  deformities 
which  mar  the  beauty,  and  to  a  certain  extent  impair  the  activity  and 
usefulness,  of  so  many  Avho  have  been  rachitic  in  ciiildhood,  may  often 
be  prevented  by  early  diagnosis  and  treatment.  Many  with  this  disease 
do  not  show  the  usual  signs  of  faulty  digestion  and  innutrition,  espe- 
cially on  casual  inspection,  for  there  may  be  considerable  adipose  de- 
velopment and  rotundity  of  features  and  form  in' a  rachitic  ciiild  ;  while, 
on  the  other  hand,  there  arc  numerous  instances  of  malnutrition  and 
wasting  without  rachitis.  Early  diagnosis,  when  the  affection  is  of  a 
mild  type,  is  necessarily  difficult,  but  a  watchful  and  painstaking  phy- 
sician will  commonly  detect  the  disease  before  it  has  run  many  weeks, 
if  he  bear  in  mind  its  fre([uency,  and  carefully  examine  the  patient. 

If  called  to  a  suspected  case,  we  should  inquire  into  the  history  and 
particularly  whether  there  have  been  signs  of  intestinal  catarrh  or  in- 
nutrition. The  gums  should  be  inspected  to  ascertain  Avhether  there 
is  backwardness  in  dentition,  and  the  head,  to  note  its  shape  and  size, 
whether  it  is  elongated,  or  wliether  it  approximates  the  square  sliape, 
with  broad  forehead  and  lai'ge  protuberances.  We  shouUl  notice  also  the 
state  of  the  fontanelles  and  sutures,  and  whether  softening  and  thinning 
of  the  cranial  bones  be  present.  The  costo-chondral  articulations  and 
those  of  the  wrist,  should  also  be  carefully  examined  to  ascertain  if 
there  is  any  enlargement,  and  the  shape  of  the  thorax,  which  begins 
to  exhibit  the  rachitic  deformity  at  an  early  stage  of  the  disease,  should 
likewise  be  noticed.  We  should  also  examine  the  child  in  reference  to 
other  less  prominent  signs,  such  as  spinal  curvature,  abdominal  pro- 
tuberance, muscular  weakness,  and  relaxation  of  ligaments  (which  pro- 
duce feeble  and  unsteady  use  of  the  limbs),  perspirations  upon  the  head 
and  neck  from  slight  excitement,  and  during  sleej),  fretfulness,  etc.  If 
rachitis  be  present,  certain  of  these  signs  will  be  observed. 

The  late  Dr.  Parry  called  attention  to  the  importance  of  making  a 
differential  diagnosis  between  the  pseudo-paraplegia  of  rachitis  and  true 
paraplegia,  which  is  the  prominent  symptom  of  infantile ptaralifiiix.  The 
rachitic  child,  from  muscular  weakness  and  ligamentous  relaxation,  and 
from  the  soreness  and  tenderness  common  in  this  condition,  may  seldom 
use  his  legs;  may  sit  or  lie  (piietly  at  the  age  when  healthy  children, 
if  awake,  arc  constantly  moving  their  lind>s.  If  we  attempt  to  make 
him  walk  or  stand,  his  legs  may  be  so  limp  and  powerless  that  they 
give  way  under  his  weight,  but  this  is  a  different  state  from  paralysis. 


132  RACHITIS. 

In  paralysis,  the  fault  is  in  the  nervous  system — usually  in  the  nervous 
centres — whereas,  in  rachitis,  it  is  in  the  muscles  and  ligaments.  'J'he 
rachitic  child,  Avhen  sitting  or  lying  down,  readily  moves  his  legs  if  his 
feet  be  tickled  or  pinched,  while  the  paralyzed  limb  responds  to  the  irri- 
tation imperfectly.  In  infantile  paralysis,  the  loss  of  muscular  power 
is,  with  few  exceptions,  confined  to  the  muscles  of  the  lower  extremities; 
but  in  rachitis,  the  muscular  feebleness  is  more  general,  being  notice- 
able in  the  arms  as  well  as  in  the  legs.    Great  relaxation  of  the  ligaments 

.  .  .  .  .         ^ 

is  in  most  instances  due  to  rachitis.     It  is  especially  noticeable  in  the 

ankle  and  knee-joints,  and  is  a  diagnostic  sign  which  should  not  be  over- 
looked in  the  examination  of  a  suspected  case  of  the  disease. 


Prognosis  of  Rachitis. 

The  prognosis  of  rickets  is  usually  favorable,  provided  that  no  serious 
complication  arises.  Rachitis  is  not  in  itself  fatal,  under  ordinary  cir- 
cumstances. If  there  be  much  lateral  depression  and  narrowing  of  the 
thorax,  the  functions  of  the  heart  and  lungs  may  be  embarrassed,  and 
if  the  patient  have  a  severe  bronchial  catarrh  or  hroncJio-pneumonia, 
the  condition  becomes  one  of  danger.  Rachitic  children  seem  to  be 
especially  liable  to  catarrhal  attacks  of  the  air-passages,  and  even  a 
moderate  catarrh,  with  a  deformed  thorax,  may  prevent  proper  decar- 
bonization  of  the  blood,  and  cause  lividity  and  dyspnoea.  Therefore, 
now  and  then,  a  rachitic  child  succumbs  to  an  attack  of  inflammation 
of  the  respiratory  apparatus,  which  would  not  have  been  fatal  if  there 
had  been  no  rachitic  deformity.  We  have  seen  that  in  Avhatever  way  it 
may  act  to  produce  this  form  of  spasm,  rachitis  is  a  cause  of  laryngismus 
stridulus.  Occasionally  spasm  of  the  glottis  is  fatal,  but  cases  with 
such  a  termination  are  rare  in  America,  though  not  infre(i[uent  in  some 
European  countries. 

Of  the  diseases  of  childhood  which  rachitic  children  tolerate  badly, 
and  which  may  prove  fatal  in  consequence  of  rachitic  bone-softening 
and  deformity,  pertussis  should  be  mentioned,  If  this  be  severe  while 
the  ribs  are  soft  and  yielding,  and  there  be  lateral  depression  of  the 
thorax,  the  spasmodic  cough  produces  great  suffering  and  involves 
danger.  Lividity,  feeble  action  of  the  heart,  pulmonary  and  cerebral 
congestion,  and  eclampsia,  may  occur.  Measles,  if  it  be  attended  by 
considerable  bronchitis,  and  especially  if  it  be  complicated  by  broncho- 
pneumonia, is  also  one  of  the  dangerous  intercurrent  diseases.  The 
gravity  of  these  inflannnations  of  the  respiratory  apparatus  is  usually 
proportionate  to  the  degree  of  recession  of  the  ribs  during  inspiration. 
With  these  exceptions,  and  Avith  that  of  risk  to  the  married  female  who 
has  deformity  and  stunted  growth  of  the  pelvic  bones,  the  rachitic  are 
not  liable  to  any  ulterior  serious  conse(juences.  Minor  deformities,  in 
mild  cases,  not  infrequently  disappear  in  the  subsetjuent  growth  of  the 
skeleton.  The  older  the  child  is  when  rachitis  begins,  the  milder  is 
ordinarily  the  form  of  the  disease,  and  the  more  speedy,  consequently, 
the  recovery,  and  the  less  the  deformity.  In  the  gravest  cases,  the 
disease  will  almost  always  be  found  to  have  begun  under  the  age  of  one 
year. 


TREATMENT.  133 


Treatment  of  Rachitis. 

Since  rachitis  sometimes  develops  in  the  fcetus  it  is  important,  in 
order  to  prevent  this  malady,  that  the  parentage  be  liealtln\  The 
pregnant  woman  should  lead  a  quiet  and  regular  life,  with  suflicient  ex- 
ercise to  produce  healthy  digestion,  but  without  too  arduous  work,  and 
with  regular  meals  and  wholesome  diet.  By  the  observ^ance  of  such 
rules  foetal  rachitis  might  probably,  in  most  instances,  be  prevented. 
Most  cases  of  rachitis,  however,  commence  in  infancy,  so  that  by  proper 
management  of  the  infant,  we  may  hope  to  prevent,  and  usually  can 
prevent  the  occurrence  of  tliis  disease. 

The  correct  treatment  of  rachitis  is  apparent  when  we  consider  its 
character  and  the  nature  of  its  causes.  Tiie  obvious  indication  is  to 
restore  healthy  nutrition.  This  requires  both  hygienic  and  therapeutic 
measures.  The  apartment  in  which  the  child  resides  should  be  dry, 
airy,  and  plentifully  supplied  with  light.  He  should  be  taken  daily 
into  the  open  air,  in  order  to  invigorate  his  system,  but  in  such  a  Avay 
as  not  to  increase  his  suffering,  on  account  of  iiis  general  tenderness. 
Residence  in  the  country  is  far  preferable  to  that  in  the  city,  because 
of  the  better  hygienic  conditions  which  it  procures.  The  purer  air,  the 
better  diet,  and  consequently  the  more  robust  development  gained  by 
rural  life,  are  important  advantages,  to  obtain  which  is  abundantly 
worth  pecuniary  sacrifice  when  the  children  of  a  family  are  rachitic. 

The  diet  in  rachitis  should  receive  particular  attention,  since  indiges- 
tion and  gastro-intestinal  derangement  sustain  a  causative  relation  to  so 
many  cases.  Good  breast-milk  ought,  if  possible,  to  be  obtained  until 
the  child  has  reached  the  age  of  ten  months,  and,  if  the  mothers  con- 
dition be  such  that  she  cannot  furnish  it,  a  wet-nurse  should,  if  practi- 
cable, be  employed.  But  after  the  age  of  six  months  additional 
nutriment  is  required.  As  a  rule,  the  infant  should  be  weaned  at  the 
age  of  twelve  months,  but  longer  nursing  may  be  best  under  certain 
conditions,  as  the  presence  of  liot  weather,  an  abundant  supply  of  good 
breast-milk,  and,  on  the  part  of  the  infant,  feeble  digestion  and  easily 
deran<fed  diirestive  orL'ans.  In  case  breast-milk  cannot  Ije  obtained, 
cow's  milk,  properly  diluted,  according  to  the  age,  with  water,  or  with 
a  farinaceous  solution  is  the  best  substitute.  The  reader  is  referred  to 
the  chapter  relating  to  the  diet  of  infancy,  for  full  particulars  relating 
to  infant  feeding.  For  infants  with  feeble  digestion,  it  is  better  that 
the  starch  sliould  be  converted  into  glucose  before  its  use,  by  Liebig's 
or  a  similar  process.  Four  teaspoontuls  of  barley,  rice,  or  wheat  Hour, 
or  of  oatmeal,  may  be  mixed  with  a  pint  of  water,  and  boiled  with  cdu- 
stant  stirring,  five  to  ten  minutes,  when  it  is  removed  from  the  fire, 
and  cooled  to  a  blood  heat.  One  teaspoonful  of  Trommer's  mult  for  in- 
fants, Reid  k  Carnick's,  or  other  good  ])reparation  of  malt,  should 
be  added  to  this.  This  process  thins  the  starch,  and  renders  it  more 
digestible.  The  gruel  thus  prejiared  should  be  mixed  with  cow's  milk, 
in  varying  proj)ortion  according  to  the  age  of  the  infant.  It  is  pio- 
Itably  best  in  the  use  of  most  of  the  farinaceous  substances,  and  partic- 
ularly of  barley,  to  grind  in  a  coffee-mill  the  whole  kernel,  and  make 


134  RACHITIS. 

the  decoction  from  the  husk,  in  or  close  to  Avhich  the  nitrogenous  pro- 
ducts abound,  as  ^vell  as  fruui  the  interior  of"  the  seed,  in  Avhich  the  starch 
abounds  (Jacobi),  and  from  which  the  bark^y  flour  of  the  shops  is  pre- 
pared. The  decoction  shoukl  be  strained  through  a  sieve  before  adding 
the  milk.  The  importance  of  obtaining  cow's  milk  of  the  best  quality 
for  the  rachitic,  need  not  be  dwelt  upon  in  this  connection.  In  hot 
weather  in  the  cities,  it  is  usually  best  to  scald  it  as  soon  as  received, 
and  perhaps  difl'erent  times  during  the  day,  to  prevent  fermentation,  for 
sour  milk  should  never  be  used. 

Meat  soups  properly  prepared  according  to  the  age,  are  useful  addi- 
tions to  the  diet.  I  have  elsewhere  stated  that  in  one  of  the  institutions 
of  New  York,  rachitis  from  being  common  "was  made  to  disappear  almost 
entirely,  by  allowing  a  more  generous  diet,  a  part  of  which  was  the 
daily  use  of  a  little  beef-tea.  I  have  emj)loyed  with  apparently  good 
results,  beef-tea  prepared  as  follows  :  Add  half  a  pound  of  finely  hashed 
beef  to  one  pint  of  cold  water,  mix  Avith  it  ten  drops  of  dilute  muriatic 
acid,  allow  it  to  stand  cold  with  frequent  stirring  half  an  hour,  then 
place  it  upon  the  table  in  a  pail  or  large  pan  of  boiling  water,  so  as  to 
heat  it  without  coagulating  the  albumen.  In  an  hour  it  is  ready  for  use. 
The  peptonized  beef  of  the  sho])S,  as  now  prepared  by  Parke,  Davis  & 
Co.,  according  to  lludisch's  method  is  also  a  most  useful  preparation. 

Medicines  which  improve  the  general  health  are  all  more  or  less  bene- 
ficial in  the  treatment  of  rachitis,  but  lime  and  cod-liver  oil  are  especially 
indicated.      The  followin«;  formula  will  be  found  useful  in  most  cases  : 

U. — Olci  morrhu^ ^^'V. 

Aq.  calcis, 

Syr.  calcis  lactophosphatis        ....     aaf^ij. — Misce. 

Of  this,  one  teaspoonful  should  be  given  four  or  five  times  daily  to 
an  infant  of  one  year.  This  combination  agrees  Avith  the  digestive 
function,  and  is  readily  taken  by  most  infants.  Cod-liver  oil,  while  it 
improves  the  general  nutrition,  is  especially  useful  in  rachitis. 

Care  should  be  taken  to  prevent  deforinities  while  the  bones  are  soft 
and  yielding.  The  patient  should  not  be  encouraged  to  stand  or  use 
the  limbs  until  they  become  firmer.  He  should  lie  upon  an  even  and 
soft  mattress,  and  should  be  taken  into  the  open  air  in  a  carriage.  A 
uniform  support  of  body  and  limbs  is  requisite  in  order  to  prevent 
curvature. 

In  craniotabes  the  pillows  should  be  soft,  and  care  should  be  taken 
that  the  yielding  parts  of  the  cranium  should  not  be  unduly  pressed 
upon.  The  perspirations  may  be  relieved  by  sponging  with  vinegar 
and  water.  The  infant  should  be  regularly  bathed  in  water  a  little 
cooler  than  the  body,  and  rock  salt  may  be  added  to  the  bath.  The 
proper  treatment  of  laryngismus  stridulus,  which  so  frequently  com- 
plicates rachitis,  is  described  in  our  remarks  u[)on  that  disease.  Con- 
stipation, common  in  the  rachitic,  should  be  treated  by  simple  enemata, 
except  so  far  as  it  can  be  relieved  by  change  in  the  diet.  When  cur- 
vatures are  unavoidable,  orthopixidic  treatment  will  subsequently  be 
required. 

Such  is  an  outline  of  the  treatment  which  rachitis  ordinarily  requires, 


SCROFULA.  135 

but  other  medicinal  agents  may  be  found  useful  for  their  general  tonic 
action,  or  by  supplying  lime-salts  to  the  system ;  among  which  may  be 
mentioned,  the  compound  syrup  of  the  pliosphates,  the  citrate  of  iron 
and  quinia,  wine  of  iron,  the  various  preparations  of  cinchona,  columbo, 
etc.  Flieschmann  recommends  the  fluorine  compounds  in  order  to  in- 
crease and  harden  the  enamel  of  the  teeth,  employing  for  the  purpose 
the  tooth  pastille  of  Ehrhardt  or  Hunter,  which  contains  the  flouride  of 
potassium. 


CHxVPTER    II. 

.  SCROFULA. 

The  term  scrofula  {scrofa,  a  pig,  from  the  resemblance  of  the  enlarged 
cervical  glands  of  a  scrofulous  individual  to  a  swine's  neck)  is  applied  to 
a  diathesis  which  is  characterized  by  increased  vulnerability  of  the  tis- 
sues. The  nutritive  process  of  the  tissues  is  readily  disturbed  even  by 
trifling  irritants  or  agencies  in  those  who  have  this  diathesis,  and, 
therefore,  the  scrofulous  are  prone  to  inflammations  of  various  parts. 
Inflammations,  which  can  properly  be  considered  as  dependent  upon  this 
diathesis,  or  as  occurring  under  its  influence,  are  for  the  most  part  sub- 
acute or  chronic,  and  they  differ  from  ordinary  inflammations  in  the 
fact  of  a  greater  cell-formation,  and  greater  liability  to  cheesy  degener- 
ation of  inflammatory  products,  so  that  return  to  the  healthy  state  by 
absorption  is  slow  or  impossible.  Moreover,  this  diathesis,  while  it  gives 
rise  to  certain  inflammations,  wliich  do  not  occur  or  are  rare  in  other 
states  of  the  system,  and  which  all  physicians  at  once  recognize  as  scrofu- 
lous, often  modifies  those  common  inflammations  to  which  all  j)ersons, 
whether  scrofidous  or  non-scrofulous,  are  lialde,  as  coryza  and  In'on- 
chitis,  rendering  them  more  protracted  and  less  amenable  to  ordinary 
treatment. 

Scrofuhi  is  a  disease  chiefly  of  infancy  and  chihlhood.  ^^anllood, 
especially  the  first  years  of  it,  is  not  entirely  exempt,  but  scrofulous 
manifestati  is  after  the  age  of  twenty  years  are  feel)le  and  infrequent, 
disai)))earin;.  entirely  as  the  individual  advances  towards  middle  life. 
The  diathesis  is  most  active  prior  to  the  ago  of  ten  years. 

Causes. — Scrofula  is  congenital  or  acquired.  Parents  who  had  scrofu- 
lous symptoms  in  early  life,  or  Avho  are  in  a  state  of  decided  cachexia, 
as  from  cancer,  sy|thilis,  intermittent  fever,  or  tubercidosis,  are  apt  to 
beget  scrofulous  children.  Insufficient  nourishment  of  the  mother  during 
a  consiilerai)le  part  of  her  gestation,  and  advanced  age,  and  therefore 
feebleness,  of  the  father,  are  occasional  causes.  Near  blood  relationship 
of  the  parents  is  also  a  recognized  cause,  and  to  this  has  been  attributed 
the  scrofula  of  royal  families.  Children  whose  father  and  motlier  arc 
first  cousins  are,  according  to  my  observations,  likely  to  be  scrofulous. 


136  SCROFULA. 

Again,  those  born  with  sound  constitutions  may  acquire  scrofula 
through  antihygicnic  influences  in  the  first  years  of  life.  Among  the 
poor  of  New  York  Ave  often  observe  one  child  in  the  family  Avho  presents 
scrofulous  symptoms,  Avhile  the  rest  of  the  children  are  Avell,  and  in 
inany  cases  Ave  are  able  to  trace  back  the  diathesis  to  some  depressing 
cause  or  causes,  Avliich  Avere  sufficient  to  effect  the  peculiar  change  in 
the  molecular  condition  of  the  tissues  Avhich  constitutes  this  disease. 
Obviously  the  causes  of  acquired  scrofula  are  quite  numerous.  In  the 
infant  it  is  sometimes  produced  by  insufficiency  or  poor  quality  of  the 
breast-milk,  or  the  use  of  artificial  food  during  the  period  when  breast- 
milk  is  required.  Too  protracted  lactation  also,  especially  if  artificial 
food  be  almost  Avholly  Avithheld,  may  cause  it;  as  may  also,  in  those 
Avlio  have  passed  beyond  the  age  of  lactation,  the  continued  use  of  a  diet 
Avhicli  is  deficient  in  nutritive  properties. 

Residence  in  damp,  dark,  and  filthy  apartments  or  streets  may  also 
produce  it.  Hence  one  reason  of  its  frequent  occurrence  among  the  city 
poor.  Residence  in  a  small,  croAvded,  and  imperfectly  ventilated  apart- 
ment has  been  knoAvn  to  produce  it,  even  Avith  personal  cleanliness,  and 
a  diet  sufficiently  nutritive. 

Scrofula  may  also  be  caused,  in  those  previously  robust  and  of  sound 
constitution,  by  disease  of  an  exhausting  nature.  The  eruptive  fevers, 
as  smallpox,  measles,  and  scarlet  fever,  if  severe,  occasionally  produce 
this  result;  or  they  render  active  the  diathesis,  Avhich  had  hitherto  been 
latent.  In  this  city,  Avhere  chronic  entero-colitis  of  infancy  is  common, 
I  have  sometimes  been  able  to  trace  the  diathesis  to  the  cachectic  state 
and  the  impaired  nutrition  which  it  causes. 

There  is  probably  no  specific  principle  in  scrofula,  and  therefore  it  is 
not  infectious.  In  those  exceptional  instances  in  which  scrofulous  symp- 
toms appeared  after  vaccination  in  those  previoiisly  healthy,  it  is  prob- 
able that  there  were  other  more  potent  co(')|)erating  causes  than  vaccinia. 
That  vaccination  may  communicate  syi)hilis  and  erysipelas,  has  been 
shoAvn  by  many  observations.  But  Avhile  these  diseases  result  from  the 
reception  into  the  system  of  certain  poisons  peculiar  to  them ;  scrofula 
as  certainly  results  from  a  variety  of  depressing  agencies  aflfecting  the 
system  in  many  distinct  Avays,  with  the  general  result  of  impairing  its 
vigor  and  lowering  its  tone.  It  seems,  therefore,  unreasonable  to  suppose 
tliat  these  many  and  distinct  agencies  introduce  a  fixed  specific  pi'incii)le 
into  the  system,  Avhicli  causes  the  phenomena  of  scrofula.  If  there  be 
surroundings  of  a  decidedly  antihygicnic  character,  or  if  there  be  an 
inherited  predisposition  from  cachectic  parents,  the  ordinary  diseases  of 
childhood,  especially  if  severe  and  protracted,  as  scarlet  fever,  measles, 
pertussis,  and  even  vaccinia  (Henoch),  may  be  sufficient  to  cause  this  con- 
stitutional anomaly. 

The  priuiary  scrofulous  ailments,  by  Avliich  the  diathesis  is  manifested, 
occur  for  tlie  most  part  upon  one  of  the  free  surfaces,  namely,  upon 
some  part  of  the  skin  or  mucous  membrane.  Certain  standard  authors 
attribute  this  to  the  fact  that  tliese  parts  are  most  exposed  to  the  action 
of  noxious  agencies.  The  lymphatics  lying  in  the  inflamed  area  take 
up  the  altered  lynq)h  and  carry  it  to  tlie  ailjacent  lymphatic  glands, 
which    become  irritated,   and  undergo  hyperplasia,    and  perhaps  ulti- 


ANATOMICAL    CHAKACTERS.  137 

mately  suppuration.  This  is,  in  a  large  proportion  of  cases,  the  begin- 
ning of  scrofulous  ailments.  Nevertheless,  in  not  a  few  instances,  the 
first  manifestations  are  in  deep-seated  and  covered  parts,  as  when  scrofu- 
lous periostitis  or  osteitis  occurs,  without  any  peripheral  lesion. 

Anatomical  Characters. — There  are  no  ascertained  anatomical 
changes  in  the  blo(jd  which  are  peculiar  to  scrofula.  As  long  as  the 
appetite  and  general  health  remain  good,  and  the  local  affections  have 
not  occurred,  the  composition  of  this  fluid  is,  so  far  as  known,  un- 
altered. In  the  cachexia  which  is  present  when  the  general  health  is 
impaired,  the  blood  becomes  impoverished,  tlie  red  corpuscles  lose  a 
portion  of  their  coloring  matter,  and  the  watery  element  predominates. 

The  question  arises  whether  the  glandular  hyperjdasia  of  scrofula  pro- 
duces an  excess  of  white  corpuscles  in  the  blood.  Virchow  says:  "  Dur- 
ing the  progress  of  an  attack  of  scrofula,  in  which,  if  the  disease  run  a 
somewhat  unfavorable  course,  the  glands  are  destroyed  by  ulceration,  or 
cheesy  thickening,  calcification,  etc.,  an  increased  introduction  of  cor- 
puscles into  the  blood  can  only  take  place  as  long  as  the  irritato<l  gland  is 
still,  in  some  degree,  capable  of  performing  its  functions,  or  still  con- 
tinues to  exist;  as  soon,  however,  as  the  glands  are  Avithered  or  destroyed, 
the  formation  of  lymph-cells  likewise  ceases,  and  with  it  the  leucocytosis. 
In  all  cases,  on  tlie  other  hand,  in  which  a  more  acute  form  of  disturbance 
prevails,  connected  witli  inflammatorv  tumefaction  of  the  gland,  an  in- 
crease of  the  colorless  corpuscles  always  takes  place  in  the  blood."  (Cellul. 
Pathol.)  Although  the  glandular  hyperplasia  occurring  in  scrofula 
increases  the  number  of  white  corpuscles  in  the  blood,  scrofula  cannot 
be  regarded  as  sustaining  any  causative  relation  to  that  great  and  con- 
stant increase  of  white  corpuscles  which  characterizes  the  disease  leu- 
caemia; for  this  disease,  as  remarked  by  Niemeyer,  does  not  occur  in 
childhood,  when  the  scrofulous  diatliesis  is  active,  but  in  manhood,  when 
it  has  ceased  to  exist,  or  has  become  latent. 

Strumous  inflammations  of  the  cutaneous  and  mucous  surfaces,  which 
we  have  seen  are  the  initial  lesions  in  a  large  proportion  of  scrofulous 
cases,  do  not  ))resent  any  peculiar  anatomical  characters.  Some  of 
them  are  attended  by  an  abundant  formation  of  cells,  and  by  «lense  in- 
filti'ation  of  the  inflame<l  tissues;  but  inflammations  which  do  not 
depend  on  the  strumous  diathesis  have  the  same  anatomical  elements. 
The  most  marked  differences  between  the  strumous  and  non-strumous 
inflannnations  are  found  in  their  origin,  amount  of  cell-formation,  and 
duration. 

The  swelling  of  the  lymphatic  glands,  which  is  so  common  in  the 
neighborhood  of  scrofulous  ailments,  and  which  we  have  seen  is  in  most 
instances  the  result  of  "conducted  irritation,"  is  due  to  hyperplasia  of 
tlie  lymph-cells  with  comparatively  little  or  no  increase  of  the  stroma. 
Thus  hypei"plasia  of  the  cervical  glaiuls  is  connnon,  resulting  from 
eczema  of  the  scalp  or  face,  or  from  otitis,  or  any  of  the  forms  of  stom- 
atitis; arul  so  pharyngitis  often  gives  rise  to  hyperjilasia  of  the  tonsils, 
which  aie  lyiiijjliatic  glands.  The  scrofulous  nature  of  the  glandular 
enlargement  is  apparent  from  the  fact  that  it  continues  long  after  the 
primary  inflammation  which  gave  rise  to  it  has  abated.  Lymphatic 
glands  sometimes  enlarge  in  those  who  are  not  scrofulous,  either  from 


138  SCROFULA. 

direct  injury  or  propagated  inflammation,  but  the  tumefaction  is  com- 
monly less  in  degree,  and  in  most  instances  it  soon  abates  Avbcn  the  ex- 
citing cause  is  removed. 

The  glands  Avliich  most  commonly  undergo  scrofulous  enlargement 
are  the  cervical,  inguinal,  bronchial,  and  mesenteric  ;  but  in  those  who 
are  decidedly  scrofulous,  the  glands  in  the  vicinity  qf  any  protracted  in- 
flammation are  very  prone  to  liyper})lasia.  Thus  I  have  seen  enlarged 
and  cheesy  glands  in  the  vicinity  of  scrofulous  ostitis,  or  periostitis. 

Under  favorable  circumstances  the  glandular  enlargement  abates  after 
a  short  time,  by  absorption  of  the  redundant  cells.  But  the  products  of 
hyperplastic  or  inflammatory  action  in  the  scrofulous  individual  are  very 
liable  to  undergo  cheesy  degeneration,  and  the  close  causative  relation 
of  this  cheesy  substance  with  tubercles  is  now  admitted.  If  resolution 
do  not  soon  occur  in  the  gland,  it  begins  to  undergo  cheesy  degeneration. 
It  becomes  firm  and  inelastic,  its  nutrient  vessels  narrowed  and  com- 
pressed, so  that  circulation  through  it  ceases,  and  its  cells,  losing  their 
liquid  and  vitality,  shrivel  away.  This  necrobiotic  process  api)ears  in 
points  in  the  gland,  which  enlarge  and  unite,  till  finally  the  whole  gland 
becomes  a  dead  mass,  Avitii  shrivelled  elements,  of  a  whitish  appearance, 
like  cheese,  the  resemblance  to  which  has  suggested  the  name  by  which 
the  degeneration  is  known. 

In  certain  patients  cheesy  glands  act  as  an  irritant,  like  inorganic 
matter,  producing  suppurative  inflammation,  and  their  subsequent  his- 
tory is  that  of  -an  abscess.  Purulent  matter  mixed  with  the  cheesy 
debris  escapes  by  ulceration  upon  the  nearest  surface,  and  scrofulous 
ulcers  result,  which  slowly  heal,  leaving  permanent  cicatrices  ;  calcifica- 
tion of  a  cheesy  gland  occurs  in  exceptional  instances. 

The  cervical  lymphatic  glands  in  the  scrofulous  child,  having  under- 
gone hyperplasia  of  their  cellular  elements,  not  infrequently  continue 
painless  and  indolent  for  a  considerable  time,  ])roducing,  according  to 
their  size,  an  unsightly  appearance,  and  Avithout  undergoing  cheesy  de- 
generation. Finally  one  or  more  become  inflamed,  and  the  broken- 
down  gland  substance  softens  and  is  expelled,  mixed  with  pus,  through 
an  ulcerated  opening  in  the  skin. 

In  order  to  complete  the  description  of  the  anatomical  character  of 
scrofula,  it  would  be  necessary  to  describe  the  various  inflammations  to 
which  the  diathesis  gives  rise.  Those  which  are  most  common  and  im- 
portant occur  in  the  skin,  mucous  meudu-ane,  connective  tissue,  the 
joints,  the  bones  with  their  periosteal  covering,  arui  the  eye  and  ear; 
eczema  and  coryza  are  very  common  scrofulous  ailments.  Phl^'ctenular 
keratitis  with  great  intolerance  of  light,  otitis  externa,  causing  pro- 
tracted otorrhoca,  or  media  and  interna,  causing  deep-seated  pain,  Avith 
impairment  or  loss  of  hearing,  oftensive  purulent  discharge,  and,  in  the 
gravest  cases,  caries  of  the  mastoid  cells  or  caries  extending  along  the 
petrous  })ortion  of  the  temporal  bone  even  to  the  brain,  causing  men- 
ingitis and  death,  are  not  uncommon  manifestations  of  scrofula,,  in  the 
families  of  the  city  poor.  Strumous  cellulitis,  occurring  independently 
of  the  glandular  aflection,  and  quickly  ending  in  suppuration,  is  also 
common.  The  term  cold  is  applied  to  the  abscess  Avhcn  the  local  symp- 
toms are  slight,  and  there  is  but  little  heat  of  the  parts.     In  young 


A  X  A  T  O  >[  I C  A  L    CHARACTERS, 


139 


children  the  common  seat  of  these  abscesses  is  directly  under  the  skin, 
so  that  if  subcutaneous  cellulitis  running  into  an  abscess  occur  in  a 
young  child,  he  probably  has  the  strumous  diathesis. 

The  osseous  system  is  very  prone  to  inflammation  in  the  scrofulous. 
Periostitis,  ostitis,  and  arthi'itis,  rare  in  those  with  healthy  constitu- 
tions, are  common  in  the  scrofulous,  in  "whom  they  result,  even  from 
very  slight  injuries,  and  sometimes  without  the  recollection  of  any  in- 
jury, and  apparently  from  the  direct  influence  of  the  diathesis.  These 
inflammations  are  more  common  in  the  lower  extremities  than  in  the 
upper.  Periostitis  often  occurs  in  scrofulous  children  without  ostitis, 
when  its  usual  seat  is  upon  the  shafts  of  the  long  bones,  and  it  also 
accompanies  inflammations  of  the  bone,  as  pleurisy  accompanies  pneu- 
monia. The  osseous  inflammations  of  strumous  patients  are  of  two 
kinds :  first,  the  destructive,  producing  caries  with  suppuration,  or 
necrosis ;  and,  secondly,  the  so-called  fungous,  in  which  there  is  pro- 
liferation of  tissue  as  in  white  swelling.  Often  both  these  processes  co- 
e.xist,  granulations  and  new  tissue  springing  up,  while  the  carious  or 
necrotic  process  is  extending. 

Dactylitis  is  in  most  instances,  when  occurring  in  young  infjints,  a 
syphilitic  affection,  but  in  children  of  one  year  or  more,  in  whom  no 
marked  syphilitic  symptoms  have  previously  occurred,  it  originates  from 

Fig.  18. 


syp 


140  SCROFULA. 

coryza,  which  gradually  abated  under  anti-strumous  treatment.  At  the 
age  of  five  months  he  had  purpura  hemorrhagica  of  a  severe  form,  but 
apparently  not  accompanied  by  hemorrhage  from  any  of  the  mucous 
surfaces.  The  patches  of  extravasated  blood  were  quite  numerous  and 
large  over  the  trunk  and  limbs,  and  it  was  neai'ly  three  months  before 
they  entirely  disappeared.  A  few  months  suljseciuently  he  began  to 
have  offensive  otorrhoca  on  one  side,  Avliich  did  not  entirely  cease.  In 
December,  1876,  at  the  age  of  eighteen  months,  well-marked  dactylitis 
was  first  observed,  involving  the  first  phalanx  of  the  left  middle  finger. 
The  swelling  was  somewhat  tender,  and  the  skin  which  covered  it  had  a 
slightly  reddish  or  pinkish  tinge,  indicating  the  inflannnatory  nature  of 
the  malady.  Neither  joint  at  the  extremity  of  the  phalanx  was  involved, 
so  that  the  movements  were  unimi^aired.  The  dactylitis  increased 
somewhat  after  it  was  first  discovered,  and  then  began  to  decline,  under 
treatment  with  cod-liver  oil  and  syrup  of  iodide  of  iron.  The  accom- 
panying woodcut  represents  the  outlines,  obtained  by  tracing  the  hand 
of  the  infant,  when  pressed  on  paper. 

Symptoms. — The  scrofulous  diathesis  is  exhibited  by  certain  physical 
signs,  which  are  present  in  infancy,  but  are  more  manifest  in  childhood. 
In  one  class  of  strumous  children  they  are  as  folloAvs :  form,  tall  and 
slender ;  quickness  of  movement  and  perception ;  intelligence,  good ; 
skin,  thin  and  semi-transparent,  through  which  the  superficial  veins  are 
distinctly  seen  ;  features,  delicate ;  cheeks,  habitually  pallid  or  florid, 
and  flushed  by  slight  excitement ;  eyes,  bright,  with  bluish  conjunc- 
tiva; muscles  and  bones,  slender  in  proportion  to  their  length.  Those 
children  who  present  these  peculiarities  are  said  to  have  the  erethitic 
form  of  the  diathesis. 

Others  have  what  has  been  designated  the  torpid  scrofulous  habit, 
which  is  characterized  by  softness  and  flabbiness  of  the  flesh,  distended 
abdomen,  large  head,  broad  face,  slow,  languid  movements,  and  an  over- 
production of  flit  in  the  subcutaneous  connective  tissue  in  certain  situa- 
tions, especially  the  nose  and  upper  lip.  Though  typical  cases  can  be 
readily  referred  to  one  or  the  other  of  these  forms,  there  are  many 
which  are  intermediate. 

One  of  the  earliest  of  the  scrofulous  manifestations  is  subcutaneous 
cellulitis,  alluded  to  above,  giving  rise  to  abscesses,  commonly  not  large, 
with  little  surrounding  induration,  little  pain,  tenderness,  and  heat,  and 
slow  in  discharging ;  in  a  Avord,  indolent.  The  most  frequent  seat  of 
these  abscesses  is  upon  the  extremities,  but  they  may  occur  upon  the 
scalp  or  elsewhere.  They  gradually  heal  when  the  pus  escapes,  their 
site  bein'T  indicated  for  a  considerable  time  bv  the  depression  and  red- 
dish  discoloration  of  the  skin,  which  gradually  returns  to  its  normal 
state.  Ordinarily,  these  abscesses  do  no  harm  apart  from  the  reduction 
of  the  general  health  wiiich  they  effect,  but,  when  occurring  in  localities 
where  the  connective  tissue  lies  upon  the  periosteum,  as  upon  the 
fingers,  periostitis  may  result,  with  destruction  of  the  surfiice  of  the 
bone.  Again,  thrombi  may  occur  in  the  vessels  of  the  inflamed  part, 
giving  rise  to  emboli,  embolisnud  pneumonia,  and  death.  Specimens 
from  such  a  case  were  presented  by  me  to  the  New  York  Pathological 
Society  in  1808. 


SYMPTOMS.  141 

The  scrofulous  affections  of  the  skin  often  also  occur  at  an  early  age, 
even  before  dentition.  They  are  more  frequent  in  infancy  tlian  in  child- 
hood. The  most  common  are  eczema  and  impetigo,  and,  of  rare  occur- 
rence, ecthyma  and  lupus.  But  all  these  may  occur  in  those  who  are 
not  strumous  or  who  do  not  present  the  characteristics  of  the  strumous 
diathesis. 

Scrofulous  affections  of  the  mucous  surfaces  are  scarcely  less  frequent 
than  those  of  the  skin.  They  jjresent  the  ordinary  features  of  mucous 
inflammations  of  a  subacute  and  chronic  character. 

Sometimes  they  occur  without  obvious  exciting  cause ;  in  other  cases 
there  is  a  cause  of  this  kind,  such  as  exposure  to  cold ;  but  the  inflam- 
mation, once  established,  continues  on  account  of  the  diathesis.  It  is 
often  doubtful  whether  inflammations  in  strumous  subjects  be  of  such  a 
character  that  it  is  proper  to  designate  them  strumous,  especially  if  they 
occur  upon  such  surfaces  as  are  frequently  the  seat  of  ordinary  inflam- 
mation. If  the  child  have  heretofore  presented  symptoms  of  scrofula, 
if  the  inflammation  be  subacute,  and  there  be  no  apparent  cause  to 
originate  or  sustain  it  apart  from  the  diathesis,  it  is  probably  of  a 
strumous  character.  The  diagnosis  is  rendered  more  certain  by  ob- 
serving the  effect  of  anti-struraous  remedies.  The  most  frequent  of 
these  scrofulous  inflammations  of  mucous  surfaces  are  coryza,  tracheo- 
bronchitis, and  conjunctivitis.  More  rarely,  stomatitis,  pharyngitis, 
vaginitis,  and,  according  to  some,  entero-colitis,  are  of  a  strumous 
character.  Coryza  gives  rise  to  snuffling  respiration,  tlie  formation  of 
crusts  around  and  within  the  nares,  and  excoriation  of  the  upper  lip. 
The  tracheo-bronchitis  is  attended  by  thickening  of  the  mucous  mem- 
brane, increased  production  of  mucus  and  epithelial  cells,  and  a  loud 
tracheal  rale,  accompanying  each  inspiration. 

Strumous  inflammation  of  the  mucous  membrane  of  the  trachea  and 
bronchial  tubes  is  not  a  very  infrequent  disease  in  this  city.  It  some- 
times orifinates  in  a  simple  inflammation  from  cold,  or  the  tracheo- 
bronchitis  of  measles,  or  pertussis,  and  it  is  apt  to  contmue,  with  its 
nlles,  cough,  and  scanty  expectoration,  for  months,  unless  relieved  by 
a  pro])er  course  of  treatment. 

Among  the  most  common  of  the  strumous  affections,  are  inflammation 
of  the  eyelid,  designated  psorophthalmia,  and  that  of  the  eye  itself. 
The  former  is  characterized  by  redness  and  thickening  of  the  lids, 
detachment  of  the  eyelashes,  and  inflammation  and  altered  secretion  of 
the  ''Meibomian  glands;"  the  latter,  namely,  strumous  ophthalmia,  by 
jiain,  lachrymation,  ]>hotophobia,  and  a  moderate  degree  of  liypcraMuia 
of  tiie  affected  organ.  One  of  the  most  common  serious  results  of 
strumous  infljimmation  ailecting  the  eye,  arises  from  the  conjunctivitis 
and  keratitis,  namely,  the  formation  of  ])hlyctenulie  and  ulcers  on  the 
margin  of  the  conjunctiva  and  upon  the  cornea,  fed  by  newly  formed 
vessels.  If  not  controlled  by  proper  treatment,  these  may  result  in 
opneities  more  or  less  permanent,  or  possibly,  worse  still,  in  ])erforation, 
with  its  consequent  ill-effects. 

Inlliinimations  of  the  external  and  middle  ear  have  their  origin  very 
generally  in  the  strumous  diathesis.  Occasionally  there  is  an  exciting 
cause  of  the  otitis,  as  an  injury,  or  severe  constitutional  disease,  like 


142  SCROFULA. 

scarlet  fever.  Protracted  otitis,  whether  external  or  internal,  and 
especially  that  form  of  it  which  leads  to  ulceration,  destruction  of  the 
ossicles,  and  caries  of  the  petrous  portion  of  the  temporal  bone,  it  is 
proper,  in  a  large  proportion  of  cases,  to  regard  and  treat  as  strumous. 

The  stubbornness  and  frequent  disastrous  consequences  of  scrofulous 
inflammation  of  the  skeleton  are  well  known.  Nearly  every  bone,  as 
well  as  its  periosteum,  is  liable  to  tliis  form  of  inflammation,  but  some 
are  more  frequently  aftectcd  than  others.  Inflammation  of  the  bone 
may  terminate  by  resolution,  by  the  formation  of  an  abscess,  or,  and 
frequently,  by  carious  or  necrotic  destruction  of  the  bone  itself.  Ne- 
crosis is  most  apt  to  occur  in  the  shafts  of  the  long  bones,  caries  in  the 
spongy  exti-cmities  of  these  bones,  and  in  the  spongy  portions  of  tiie 
short  bones.  If  abscesses  form,  the  pus  may  finally  escape  from  the 
system  by  a  tedious  ulcerative  process,  or,  retained,  may  undergo  cheesy 
degeneration.  Scrofulous  arthritis,  if  early  detected  and  properly 
treated,  may  resolve,  leaving  no  ill-effect;  if  otherwise,  suppuration, 
ulceration,  cartihiginous  and  osseous,  and  ankylosis,  often  occur. 

Scrofulous  children  are  perhaps  no  more  liable  to  inflammation  of  the 
internal  organs  than  other  chiklren,  but  the  inflammatory  products  are 
more  liable  to  cheesy  degeneration,  and  the  prognosis  is,  therefore,  less 
favorable.  The  most  frequent  of  these  inflammations,  and  the  one  of 
chief  interest,  is  pneumonia.  Catarrhal  pneumonia,  so  frequent  in 
early  life,  whether  primary  or  secondary,  in  connection  with  measles, 
pertussis,  etc.,  is  a  disease  often  involving  grave  consequences  in  those 
Avho  are  decidedly  scrofulous ;  since,  instead  of  resolving,  the  affected 
lung-tissue  presents  a  strong  tendency  to  caseous  degeneration  ending 
in  consumption  of  the  lungs  and  death.  I  have  most  frequently  noticed 
cheesy  pneumonia  during  extensive  epidemics  of  measles,  as  a  compli- 
cation or  sequel  of  this  disease.  It  may  occur  in  those  who  are  not 
scrofulous,  if  the  vital  powers  be  greatly  reduced,  but  it  is  so  much 
more  common  in  the  scrofulous,  that  some  recent  writers  have  designated 
this  form  of  inflammation  by  the  term  of  scrofulous,  instead  of  cheesy, 
pneumonia.  From  the  fact,  however,  of  its  sometimes  occurring  in  the 
non-scrofulous,  the  term  cheesy  or  caseous,  especially,  too,  as  it  expresses 
the  anatomical  state,  seems  more  appropriate. 

The  caseous  substance  whicli  so  frequently  results  from  degeneration 
of  the  products  of  scrofulous  inflammations,  affords  a  nidus  in  Avhich 
the  tubercle  bacillus  frequently  obtains  lodgement,  and  conditions  favor- 
able for  its  propagation.  Hence  the  close  etiological  relations  of  scrofula 
or  scrofulous  inflammations  to  tuberculosis. 

Prognosis. — As  scrofula  may  be  ac(}uired  through  antihygienic  in- 
fluences, so  it  may  disappear  or  become  latent  through  influences  of  an 
opposite  character.  Therefore  the  manifestations  of  scrofula  may  be 
limited  to  a  brief  period,  or  they  may  occur  at  intervals  thi'ough  the 
whole  of  childhood,  and  the  first  yeai'S  of  youth.  When  the  diathesis  is 
inherited,  and  fostered  by  unfavorable  circumstances,  the  scrofulous  affec- 
tions appear  earliest,  are  most  varied  and  severe,  and  continue  longest. 

In  most  cases,  with  proper  treatment,  the  prognosis  is  good,  but  the 
danger  to  life  depends  on  the  nature  and  extent  of  the  scrofulous  in- 
flammation.    The  most  common  unfavorable  result  is  the  occurrence  of 


TREATMENT.  143 

pulmonary  or  general  tuberculosis  from  the  infection  supplied  by  the 
cheesy  substance,  in  the  manner  stated  above.  This  is  the  usual  result 
from  cheesy  pneumonia.  The  next  most  common  cause  of  death,  either 
directly  or  indirectly,  is  inflammation  of  the  osseous  system.  Many 
deaths  occur  from  inflammation  of  the  vertebne,  or  of  the  hip  or  knee- 
joint,  Avhen  it  has  been  allowed  to  continue  a  considerable  time  without 
proper  treatment.  Protracted  suppurative  inflammation  of  the  bones  is 
apt  to  produce  amyloid  degeneration  of  organs,  which  is  permanent,  and 
likely  to  prove  fatal,  or  death  may  occur  from  exhaustion,  witli  or  with- 
out tuberculosis.  Among  the  city  poor  meningitis  is  not  very  uncom- 
mon, consequent  on  long-continued  otitis  media  and  caries  of  the  petrous 
portion  of  the  temporal  bone.  Permanent  impairment  of  sight  and 
hearing  often  results  from  neglected  strumous  ophthalmia  and  otitis. 

At  puberty  the  strumous  afiections  gradually  become  less  frequent, 
and  they  finally  disappear  in  advancing  age.  Among  the  most  robust 
adults  are  some  who  in  early  life  presented  indubitable  symptoms  of  the 
strumous  diathesis. 

Treatmext,  Prophjlactic. — Measures  designed  to  prevent  scrofula 
are  impossible  without  the  cooperati.on  of  willing  and  intelligent  parents. 
It  is  obvious  that  the  prevention  of  congenital  scrofula  requires  the 
treatment  of  disease  or  impaired  health  in  the  parent.  If  parents 
should  be  taught,  or  should  remember,  that  good  health  in  themselves 
is  the  necessary  condition  of  tlie  inheritance  of  a  sound  constitution  in 
the  child,  and  would  adopt  such  therapeutic  and  regimenal  measures 
as  would  procure  this,  the  number  of  cases  of  inherited  scrofula  would 
be  materially  reduced. 

As  the  first  years  of  life  are  very  important,  both  for  correcting  the 
diathesis  when  inherited,  and  for  preventing  its  development  in  those 
of  sound  constitution,  cave  should  be  taken  that  the  regimen  of  the 
child  be  such  that  it  does  not  produce  deterioration  of  the  general 
health.  The  nursing  inf\int,  if  the  mother  be  in  poor  health,  should  be 
provided  witli  a  healthy  wet-nurse,  for  in  young  children  the  diathesis 
may  be  acquired  solely  by  the  use  of  food  that  is  scanty  or  of  poor 
quality.  Those  olil  cnougli  to  be  weaned  should  have  ))l;un  and  nutri- 
tious diet,  with  a  pro])er  admixture  of  animal  food.  INIoro  or  less  out- 
door exercise,  and  residence  in  a  salubrious  locality,  with  sullicicnt  air 
and  sunlight,  are  also  re([uisite. 

Curativs — Since  scrofula  originates  in  a  state  of  weakness  existing  in 
the  parent  in  the  congenital,  and  in  the  child  in  the  actpiired  form  of 
the  disease,  and  is  characterized  by  feeble  resistance  of  the  tissues  to 
irritating  agents,  the  inference  is  reasonable  that  all  tonics  have,  to  a 
certain  extent,  an  anti-scrofulous  effect  upon  the  system.  The  ordinary 
vegetable  tonics,  and  sometimes  the  ferruginous,  are  indeed  useful  in 
the  treatment  of  scrofula.  Employed  in  connection  with  proper  regi- 
meiuil  measures  they  arc  sufficient,  in  many  cases,  to  remove  the  dia- 
thesis after  a  time,  or  render  it  latent.  Besides  these  medicinal  agents, 
which  tend  to  correct  the  scrofulous  diathesis  by  their  general  tonic 
effect,  there  are  certain  others  which  experience  has  siiown  to  be  bene- 
ficial in  the  treatment  of  scrofulous  affections,  and  which  are,  therefore, 


144  SCROIULA. 

largely  used.  One  of  these  is  cod-liver  oil,  which  contains  iodine  among 
its  many  ingredients. 

Cod-liver  oil  is  useless,  or  nearly  so,  in  the  torpid  form  of  the  dia- 
thesis, which  is  characterized  by  an  increased  deposit  of  fat  in  the  sub- 
cutaneous connective  tissue,  slow  circulation,  and  sluggish  muscular 
movements.  On  the  other  hand,  in  the  treatment  of  the  erethitic  form 
it  possesses  real  value.  Its  protracted  use  in  such  c;ises  does  so  modify 
the  molecular  condition  of  the  tissues  that  they  arc  less  liable  to  inflam- 
mation, and  the  diathesis  is,  therefore,  rendered  milder  or  removed. 
From  one  to  three  teaspoonfuls,  according  to  the  age,  should  be  given 
three  times  daily.  AVliile  we  frequently  experience  so  much  difficulty 
in  administering  it  to  adults  affected  with  tuberculosis,  and  sometimes 
find  it  necessary  to  discontinue  its  use  on  account  of  its  nauseating 
effect,  scrofulous  children  rarely  refuse  to  take  it,  and  it  does  not  seem 
to  diminish  their  appetite. 

Iodine  is  justly  celebrated  as  a  remedy  in  the  treatment  of  scrofulous 
maladies,  but  it  is  a  question  whether  it  has  not  been  overrated  as  a 
remedy  for  the  diathesis  itself.  Iodine  employed  internally  is  especially 
serviceable  in  glandular  hyperplasia,  and  in  scrofulous  thickening  and 
induration  of  the  connective  tissue  and  periosteum.  In  general,  it 
should  not  be  administered  to  children  in  its  isolated  state,  on  account 
of  its  irritating  properties,  but  one  of  its  compounds  sliould  be  employed. 
The  compounds  which  are  chiefly  prescribed  in  tiie  treatment  of  scrofula 
are  the  iodides  of  starch,  iron,  potassium,  and  sodium.  If,  as  is  fre- 
quently the  case,  the  patient  be  pallid,  and  his  appetite  poor,  the  iodide 
of  iron  should  be  preferred;  if  not  in  this  cachectic  state,  the  iodide  of 
starch  may  be  used.  Pharmaceutists  prepare  syrups  of  both  these 
iodides,  so  that  they  can  be  readily  administered  to  the  youngest  child. 
The  iodide  of  starch  may  be  administered  by  dropping  fi-om  one  to  five 
drops  of  the  officinal  tincture  of  iodine  on  a  little  powdered  starch,  and 
giving  it  in  syrup.  These  iodides  are  i)referable  to  the  iodides  of 
potassium  and  sodium  for  internal  administration  to  children,  as  they 
are  not  irritating  to  the  mucous  membrane,  and  the  iodine  is  readily  set 
free.  Prof.  Dalton  has,  indeed,  demonstrated  that  the  iodide  of  starch 
is  decomposed  in  most  of  the  li(|uids  of  the  body,  and  the  iodine  liberated. 

In  New  York  City  a  large  proportion  of  the  scrofulous  children  are 
cachectic,  and  need  iron,  and  the  iodide  of  iron  is  more  frequently  em- 
ployed, and  with  good  results,  than  any  other  iodine  compound.  The 
syrup  of  the  iodide  of  iron,  which  is  readily  absorbed,  should  be  given 
in  one  to  two-drop  doses  three  times  daily  to  a  child  of  six  months,  and 
one  additional  drop  added  for  each  additional  year.  Among  the  vaunted 
remedies  of  scrofula  arc  phosphoric  acid  and  the  phosphate  of  lime.  I 
have  not  employed  these  agents  without  at  the  same  time  using  other 
remedies,  and  cannot  say,  therefore,  to  what  extent  they  have  been 
curative  in  my  practice.  Probably  there  is  no  better  combination  of 
remedies  for  the  strumous  diathesis  than  the  following,  which  is  now 
used  in  some  of  the  institutions  of  New  York,  and  which  we  have  already 
recommended  in  the  treatment  of  rachitis. 

R. — 01.  morrhufc 2  parts. 

Syr.  calcis  lactophosphat 1  part. 

Aquajcalcis 1  part. — Miscc. 


TREATMENT.  145 

Dose,  one  teaspoonful  to  a  dessertspoonful  three  or  four  times  daily,  to 
each  dose  of  Avhieh,  the  syrup  of  the  iodide  of  iron  may  be  added. 

The  internal  use  of  mercury  as  an  antidote  for  scrofula  is  now 
generally  discarded.  Unless,  perhaps,  in  those  cases  in  Avhich  the 
diathesis  is  immediately  dependent  on  syphilis,  its  use  for  this  purpose, 
from  what  we  know  of  its  therapeutic  effects,  would  probably  be  more 
injurious  than  beneficial.  Among  the  medicines  which  have  from  time 
to  time  been  employed  for  the  cure  of  scrofula,  some  of  which  have  had 
considerable  reputation  but  have  nearly  flillen  into  disuse,  are  walnut 
leaves,  sarsaparilla,  elecampane,  conium,  digitalis,  horseradish,  com- 
pounds of  silver,  gold,  arsenic,  baryta,  and  bromine.  It  is  probable 
that  none  of  these  has  any  effect  on  scrofula  or  scrofulous  ailments, 
except  such  as  improve  the  appetite  and  general  health,  as  horseradish. 
The  same  hygienic  measures  are  required  in  the  treatment  of  scrofula 
which  arc  employed  in  the  ))rophylaxis  of  it.  The  nursing  infant  should 
have  healthy  breast-milk,  and  if  its  mother  belong  to  a  tubercular  o*" 
scrofulous  family,  or  be  feeble,  a  healthy  wet-nurse  should  be  employee 
or  it  should  be  sent  to  the  country,  where  suitable  cow's  milk  as  well  as 
pure  air  can  be  obtained.  The  expressed  juice  of  beef  slightly  boiled, 
the  peptonized  beef,  or  beef-tea  prepared  as  recommended  for  rachitic 
infants,  given  several  times  daily  in  small  quantity  to  infants,  aids  mate- 
rially in  restoring  a  better  nutrition  of  the  tissues.  Obviously,  similar 
care  is  necessary  in  the  selection  and  preparation  of  the  food  of  children 
who  have  passed  beyond  the  period  of  infancy.  While  the  diet  should  be 
highly  nutritious,  it  should  be  plain  and  easily  digested,  and  given  at 
efficient  intervals,  so  as  not  to  overtax  digestion. 

Fresh  air,  out-door  exercise,  daily  bathing,  personal  and  domiciliary 
cleanliness,  are  very  necessary  for  the  successful  treatment  of  the  dia- 
thesis. Since  scrofula  is  comparatively  infrequent  in  fiirming  sections, 
Bcrofulous  families  are  greatly  benefited  by  farm  life,  Avith  all  the  acces- 
Bories  to  health  which  pertain  to  it. 

The  local  scrofulous  ailments  re(juirc  additional  and  special  treatment. 
Those  located  on  the  cutaneous  and  mucous  surfaces  are  less  dangerous, 
a-s  a  rule,  than  the  deeper  seated  inflammations;  still  they  should  be 
promptly  treated,  not  only  for  the  inconvenience  and  annoyance  which 
they  cause,  but  because  they  are  apt  to  lead  to  hyperplasia  of  the  neigh- 
boring glands,  ■which  sometimes  proves  serious.  Thus  ])haryngitis  may 
cause  a  perij)haryngeal  adenitis  and  abscess,  and  a  bronchitis  may  cause 
adenitis  of  the  bronchial  glands,  Avith  the  ])robability  of  their  cheesy 
degeneration.  The  so-called  bronchial  phthisis  is  believed  to  result,  in 
a  large  proportion  of  cases,  from  a  strumous  bronchitis  which  lias  been 
allowed  to  run  on  uncontrolled  by  medicine,  and  a  similar  state  of  the 
mesenteric  glands  may  result  from  intestin'd  catarrh.  Inilamination  of 
the  skin  or  mucous  surface  occurring  in  the  strumous,  re([uires  the  con- 
tinued use  of  antistrumous  remedies,  conjoined  wdth  such  treatment, 
designed  to  act  locally,  as  is  appro])riate  for  the  case. 

It  is  the  common  practice  to  treat  the  enlarged  glands  of  struma  by 
daily  applications  over  them  of  the  stronger  iodine  pre])arations.  This 
treatment  does  not  cause  absorption  of  the  i-ethindant  gland  substance. 
It  causes  proliferation   of  the  epidermic  cells,  and  (j[qickens  the  cell 

10 


146  SCROFULA. 

change  in  the  gland  underneath,  so  that  leucocytes  are  liable  to  form  in 
it.  Cutaneous  inflamnuition,  as  eczema  or  impetigo,  causes  hyperplasia 
of  the  lymphatic  glands  underneath.  In  like  manner  strong  applications, 
which  irritate  the  skin,  are  apt  to  quicken  the  cell  formation,  so  that 
suppuration  is  a  common  result.  I  once  produced  accidentally  such  an 
amount  of  vesication  over  an  enlarged,  hard,  and  apparently  indolent 
gland  in  an  infant  of  fourteen  months,  that  I  was  very  anxious  lest  a 
sore  would  result,  which  would  heal  with  difficulty,  and  yet  instead  of 
dispersion  of  the  glandular  swelling  the  pathological  processes  were  so 
promoted  that  suppuration  and  discharge  of  pus  occurred  by  the  time 
that  the  cuticle  had  reformed. 

We  know  no  better  substance  for  the  local  treatment  of  strumous 
adenitis  than  iodine,  and  it  should  be  applied,  in  my  opinion,  in  such  a 
manner  that  it  is  absorbed  with  the  least  possible  irritation  of  the  gland. 
The  following  Avill  be  found  useful  ointments  and  solutions  for  the  treat- 
ment of  these  cases : 

R. — Potas.  iodidi ^j. 

Uiig.  stramonii Jj. 

To  be  rubbed  over  the  gland  several  times  daily.  It  should  not  be 
applied  as  a  plaster,  as  it  is  too  irritating  and  will  vesicate.  I  have 
known  a  glandular  swelling,  which  had  continued  about  three  months, 
to  disappear  in  three  weeks  under  its  use  in  connection  with  internal 
remedies.  Vaseline,  in  place  of  the  stramonium  ointment,  makes  a  nicer 
preparation.  Another  useful  iodine  mixture  for  these  cases  is  the 
following  • 

R. — Liq.  iodinii  composita, 
Glj'cerinpe,  equal  parts. 

To  be  applied  as  an  inunction.  Glycerine  renders  the  skin  soft  and  in 
a  state  favorable  for  absorption. 

In  Tlie  Medical  Press  and  Circular  for  August  3,  1870,  J.  Waring 
Curran  states  that  he  has  used  with  great  success  what  he  designates  a 
new  iodine  paint,  consisting  of  half  an  ounce  of  iodine,  the  same  quantity 
of  iodide  of  ammonium,  twenty  ounces  of  rectified  spirits,  and  four 
ounces  of  glycerine. 

Mercurial  ointments  have  been  recommended  by  writers  of  reputation 
for  the  treatment  of  these  glands.  I  have  employed  them,  and  known 
them  to  be  employed,  but  cannot  say  that  I  have  ever  observed  any 
benefit  whatever  from  their  use.  In  the  children's  class  at  the  Out-door 
Department  at  Bellevue  we  have  discarded  them  entirely  for  this  pur- 
pose, although  both  tlie  citrine  and  white  precipitate  ointments,  diluted 
with  an  equal  quantity  of  lard,  have  been  used  with  apparent  benefit  for 
chronic  coryza  of  a  strumous  nature,  and  also  occasionally  for  external 
otitis  of  the  same  nature. 

In  a  paper  read  at  the  meeting  of  the  British  Medical  Association  in 
1870,  by  Mr.  Jordnn,  the  writer  recommends,  as  attended  with  success, 
vesication,  not  over  the  gland,  but  at  a  little  distance  from  it,  as,  for 
example,  behind  the  neck,  for  treatment  of  the  cervical  glands.  But  a 
mode  of  treatment  which  seems  so  unlikely  to  be  beneficial  requires 
stronger  proof  of  its  utility  than  has  yet  been  presented. 


STRUMOUS    DISEASE    OF    THE    JOINTS. 


147 


Fia.  19. 


A  verv  important  adjuvant  to  the  external  use  of  iodine  over  an 
inflamed  gland  is  the  constant  application  of  cold.  A  small  India-rub- 
ber bag  containing  ice,  or  muslin  frec^uently  wrung  out  of  ice-water  and 
applied  over  the  gland,  contracts  the  vessels,  diminishes  the  activity  of 
the  morbid  process  going  on  underneath,  and  aids  materially  in  the  reso- 
lution. When  the  gland  becomes  so  actively  inflamed,  or  the  inflamma- 
tion so  advanced  that  redness  of  the  skin  occurs,  applications  of  iodine 
are  no  longer  proper.  They  increase  the  local  disease.  There  is  no 
longer  any  probability  of  resolution  of  the  gland,  and  poultices  should 
be  applied. 

It  is  important  that  the  diseases  of  the  osseous  system  should  receive 
early  treatment,  but,  unfortunately,  it  is  in  reference  to  these  inflamma- 
tions that  error  of  diagnosis  is  frequently  made.  Thus  I  have  known 
periostitis,  with  the  diffused  redness  of  the  skin  and  heat  Avhicli  it  pro- 
duces, to  be  mistaken  for  erysipelas,  until  the  diagnosis  was  corrected 
from  its  persistence  and  non-extension.  It  is  remarkable  that  strumous 
arthritis  sometimes  appears  in  two  or  more  joints  at  once,  as  in  the  case 
related  below.  I  have  known  it  to  occur  nearly  simultaneously  in  three 
joints,  though  only  for  a  brief  time  in  tAvo  of  the  joints,  while  it  was 
chronic  in  the  other.  Hence,  the  fact  that  this  inflammation  is  often 
mistaken  for  inflammatory  rheumatism,  and  treated  as  such  for  some 
days,  till  its  nature  becomes  apparent;  and  in  like  manner  the  febrile 
movement,  lassitude,  abdominal  pain,  etc.,  of 
vertebral  caries  are  in  a  large  proportion  of  cases 
attributed  to  something  else,  and  the  true  dis- 
ease not  suspected  till  irreparable  damage  has 
occurred,  or  much  longer  confinement  and  treat- 
ment required  than  would  have  been  necessary 
with  an  earlier  diagnosis. 

Tiie  common  strumous  inflammations  of  the 
osseous  system  which  involve  the  joints,  as  Pott's 
disease,  hip-disease,  and  white  swelling,  are 
usually  quite  amenable  to  treatment,  early  applied, 
which  insures  complete  rest;  but,  as  a  rule,  cases 
neglected,  or  wrongly  treated,  go  from  bad  to 
worse.  There  are  exceptions,  for  a  case  may  do 
well  or  terminate  witli  moderate  deformity  with- 
out treatment,  as  in  the  following  interesting  in- 
stance, which  also  shows  the  difficulty  which 
often  attends  diagnosis : 

Anna  D.,  aged  six  years,  came  to  the  children's 
class  in  the  Out-door  Department  at  Bellevuc  in 
February,  1H7T,  with  the  following  history  :  Her 
health  was  good  till  two  years  ago,  when  she  com- 
plained of  pain  of  a  mild  form  in  both  knees. 
Her  parents  attributed  it  to  her  rapid  growth, 
and  she  was  always  nl)le  to  walk  with  little  suffer- 
ing. Slowly  but  steadily  these  joints  began  to  swell.  She  has  had  no 
pain  in  other  joints,  and  no  member  of  the  family  has  ha<I  rheumatism 
except  a  grandparent.     She  walks  without  complaint  to  the  rooms  of 


148  STRUMOUS    OPHTHALMIA. 

the  Bureau.  The  aifected  joints  are  ahout  equally  swollen,  and  it  is 
evident  on  examination  that  they  contain  some  serous  effusion.  Direct 
pressure  is  not  painful,  but  pressing  the  bones  together  Avith  a  tAvisting 
or  rotating  movement  gives  some  pain.  She  is  pale,  and  has  a  stru- 
mous aspect.  A  sister  of  fifteen  years  has  a  similar  swelling  of  one 
knee,  which  began  at  the  age  of  seven  or  eight  years,  but  which  has 
received  no  regular  treatment,  }:as  not  prevented  the  free  use  of  the 
limb,  and  has  given  her  little  inconvenience. 

The  physicians  who  have  examined  this  child,  one  of  whom  is  an 
expert  in  orthopedic  surgery,  agree  that  the  disease  is  strumous  and 
not  rheumatic,  and  that  it  did  not,  during  two  years  of  neglect  and  un- 
restrained motion,  go  on  to  suppuration  and  destruction  of  the  joints, 
Avas  probably  due  to  her  good  general  health. 

Though  the  result  in  the  above  case  was  good,  since  there  was  little 
impairment  in  the  use  of  the  joints,  and  no  suffering,  yet  delay  and 
neo-lect  in  the  treatment  of  those  strumous  inilammations  which  in- 
volve  the  joints  are  exceedingly  dangerous,  for  if  left  to  themselves 
they  most  frequently  end  in  suppurative  inflammation  and  ulceration, 
with  all  the  sad  consequences  which  these  entail.  Strumous  inflamma- 
tions of  the  osseous  system  now  receive  more  early  and  correct  treat- 
ment than  formerly,  and  orthop?edia,  almost  unknown  till  within  the 
last  twenty  years,  has  become  an  important  branch  of  surgery.  For- 
merly in  New  York,  especially  in  the  tenement  houses,  we  often  met 
emaciated  bed-ridden  children  with  strumous  osteitis  and  arthritis,  their 
limbs  swollen,  and  painful  in  motion,  and  offensive  from  the  discharge, 
for  the  most  part  shunned  by  physicians,  and  with  no  prospect  of  relief 
except  by  amputation.  Now  this  spectacle  is  comparatively  infrequent. 
The  early  symptoms  of  these  diseases  being  better  understood  and  sooner 
recognized,  the  plaster  of  Paris  or  starch  dressing  to  insure  immobility, 
or  ingeniously  devised  steel  splints,  which  produce  extension,  and  allow 
motion  of  the  limb  without  friction  of  the  inflamed  surfaces,  coming 
into  general  use,  a  large  proportion  of  cases  do  not  go  beyond  the  first 
stage  and  are  cured. 

Strumous  Ophthalmia. 

( Written  hy  Dr.  0.  D.  Pomeroy^  Surgeon  to  the  Manliattnn  Eye  and  Ear  Hospital.) 

Strumous  opl)thalmia  in  young  children,  as  described  by  the  older 
writers,  is  simply  a  keratitis,  or  inflammation  of  the  cornea,  and  is 
usually  of  the  following  varieties :  phlyctenular  or  herpetic  keratitis, 
and  diffuse  or  parenchymatous  keratitis.  Perhaps  it  is  a  misnomer  to 
designate  these  affections  strumous.  This  general  principle  governs 
most  cases  of  these  inflammations,  to  Avit,  depressed  vital  energy,  which 
of  course  is  the  prominent  characteristic  of  the  strumous  diathesis. 
As  is  Avell  knoAvn,  the  cornea  is  a  tissue  of  low  vital  power  and  any 
constitutional  state,  accompanied  by  depression,  predisposes  to  an 
attack  of  keratitis.  One  of  the  commonest  hospital  experiences  is  to 
see  a  mild  case  of  catarrhal  conjunctivitis,  which  should  1:>e  self-limiting, 
gradually  extend  to  the  cornea,  causing  an  ulcerative  keratitis.     I  be- 


PHLYCTENULAR    KERATITIS.  149 

lieve  all  oplithalmic  surgeons  hold  that  the  presence  of  corneal  disease, 
not  dependent  on  an  obvious  or  specific  cause,  points  to  diminished 
vitality  on  the- part  of  the  patient. 

Herpetic  or  iMijctenular  keratitis  is  the  most  frequent  variety  of 
corneal  disease  in  children.  It  is  a  question  whether  it  commences 
with  a  vesicle  on  the  cornea,  or  a  papule;  but  in  either  case  it  soon 
becomes  an  ulcer.  Ciliary  injection  probably  precedes  it,  though  this 
can  by  no  means  be  always  observed.  In  some  patients  the  charac- 
teristic symptom,  to  wit,  photophobia,  may  exist  for  a  long  time  without 
injection  of  the  eyeball,  or  any  corneal  changes  Avhatever,  but  sooner  or 
later  it  is  probable  that  other  characteristic  signs  of  the  disease  will 
make  their  appearance.  The  photophobia  is  frequently  accompanied 
by  blepharospasm,  making  it  well-nigh  impossible  to  separate  the  eye- 
lids. When,  however,  this- is  accomplished,  abundant  tears  gush  forth, 
the  child  exhibiting  signs  of  extreme  distress.  When  the  vesicle  or 
papule  is  in  a  state  of  ulceration  in  the  earlier  stage,  there  may  only  be 
seen  a  minute  loss  of  corneal  tissue,  without  any  opacity  whatever. 
Soon,  however,  the  ulcer  becomes  more  or  less  opaque,  perhaps  seeming 
to  be  only  a  minute  whitish  spot  on  the  cornea.  This  usually  shows 
the  commencement  of  reparative  action.  If  the  disease  continue  long 
a  general  conjunctivitis  sets  in,  more  especially  of  the  ocular  conjunctiva. 
Frequently  there  will  be  only  one  or  not  more  than  two  or  three  ulcers, 
but,  in  exceptional  cases,  the  cornea  may  have  the  periphery  studded 
with  phlyctenule,  wnich,  instead  of  promptly  healing,  prolifei"ate  so  as 
to  form  elevated  nodules,  the  so-called  "scrofulous  nodular  bands."  If 
the  ulcer  in  any  case  continue  long,  a  number  of  bloodvessels  shoot  out 
from  the  conjunctival  border  of  the  cornea,  quite  up  to  the  ulcer,  pro- 
ducing what  may  be  termed  a  vascular  keratitis.  The  discharge  from 
the  eve  is  often  very  acrid,  causing  catarrh  of  the  lachrvmal  ducts,  and 
even  of  the  nares.  Herpetic  or  eczcmatous  eruptions  on  the  cheeks,  or 
the  lip  near  the  nostrils,  are  often  seen,  and  may  sometimes  appear  to 
be  the  cause  of  the  disease  rather  than  the  effect.  In  this  condition  the 
upper  lijj  may  swell  considerably,  giving  the  patient  a  very  "strumous" 
look. 

Tlie  duration  of  phJijctenular  keratitis  is  exceedingly  variable ;  two 
or  thi-ec  weeks  may  bring  it  to  a  close,  or  it  may  continue  many  months. 
The  condition  of  the  constitution  probably  determines  its  duration  as 
much  as  any  other  factor.  Of  course,  if  an  ulcer  perforate  the  cornea 
staphyloma  may  result,  rendering  recovery  more  tedious  and  incom- 
plete. TJie  diajnosi.'i  of  this  malady  is  not  difficult.  The  photophobia 
so  charactei'istic  of  keratitis,  is  present  in  no  other  disease  except  iritis, 
and  the  latter  children  rarely  have;  the  little  S|)eck,  spot,  or  abrasion 
on  the  cornea,  together  with  the  intolerance  of  light,  is  well-nigh  diag- 
nostic. Photophobia  is  present  in  most  forms  of  corneal  disease,  though 
not  in  all.  7' he  causes  of  phlyctenular  keratitis  are  about  as  follows: 
Any  condition  of  the  system  known  as  strumous,  or  whatever  tends  to 
lower  the  vital  powers  of  the  patient,  affords  a  ])redisposing  cause.  I 
am  impressed  with  the  idea  that  exposure  to  cold  or  sudden  change  of 
teni[)erature  is  the  common  exciting  cause,  barring  any  cutaneous  dis- 
eases which  may  i)as3  from  the  skin  to  the  eye.     Naturally  any  cause 


150  STRUMOUS    OPHTHALMIA. 

wliich  produces  a  conjunctivitis  may  also  produce  this  disease  second- 
arily. The  process  of  dentition  may  have  something  to  do  with  the  eye 
disturbance,  or  any  disorder  of  the  intestinal  canal ;  the  latter,  however, 
being  rather  predisposing  than  exciting  causes.  This  disease  also 
frequently  occurs  in  patients  affected  with  aural  or  nasal  catarrh,  but 
the  condition  of  such  children  trenches  closely  on  the  state  designated 
"strumous." 

The  2^>'of/nosi8  in  a  large  number  of  cases  is  very  favorable.  The 
opacities  of  the  cornea  left  after  the  healing  of  the  ulcerations  are  the 
principal  difficulties  in  the  way  of  a  good  recovery.  If  the  opacities  are 
in  the  proper  substance  of  the  cornea,  we  are  not  certain  that  they  will 
disappear  by  absorption,  though  they  may.  Nothing  is  more  difficult 
than  to  determine  this  point.  In  the  epithelial  and  Bowman's  layers, 
as  well  as  the  posterior  layer,  opacities  readily  disappear.  When  the 
ulcer  perforates  the  cornea  we  have  an  anterior  synechia  and  the  ap- 
pearance known  as  my ocepl talon,  which  usually  disfigures  the  eye  more 
or  less  for  life. 

One  discouraging  point  about  these  opacities  is  that,  though  they 
disappear,  the  cornea  is  left  with  a  somewhat  distorted  curvature,  causing 
irregular  astigmatism,  and  if  they  chance  to  be  near  t)ie  centre  of  the 
cornea,  great  disturbance  to  vision  results.  I  have  often,  in  fitting 
spectacles,  noticed  that  the  patient's  vision  showed  an  unaccountable 
lowering,  and  on  investigation  have  found  a  history  of  an  infantile 
keratitis  which  had  done  all  the  mischief  In  those  cases  described  as 
having  "scrofulous  nodular  bands,"  the  proliferative  nodules  are  very 
likely  to  undergo  a  variety  of  degenerations  Avhich  do  not  end  in  a 
properly  restored  cornea.  One  great  difficulty  in  making  an  exact 
statement  here  is  the  tendency  of  the  keratitis  to  recur,  and  there  is  no 
knowing  where  the  process  will  cease,  after  a  number  of  recurrences. 

Treatment. — As  the  fifth  nerve  presides  over  the  ciliary  vaso-motory 
system  of  the  corneal  nutritive  supply,  it  is  obvious  that  treatment 
calculated  to  correct  any  of  its  morbid  manifestations  Avould  be  rational. 
Such  is  found  to  be  the  fact.  Sulphate  of  atropia,  in  from  one  to  two 
grain  solutions,  dropped  into  the  eye  three  times  daily,  is  probably 
superior  to  any  other  treatment.  It  inclines  to  break  up  the  orbicular 
spasms,  relieving  the  photophobia  and  ciliary  neuralgia,  diminishes  vas- 
cularity, and  contributes  more  to  the  relief  of  the  patient  than  any  other 
one  remedy.  If  the  pain  be  severe  the  atropine  may  be  used  six  or 
eight  times  daily,  or  even  it  may  be  instilled  every  fifteen  or  twenty 
minutes,  until  pain  is  relieved.  If  an  over-effect  be  reached  the  patient 
complains  of  dryness  in  the  throat,  possibly  pain  in  the  head,  or  he  may 
have  other  cerebral  disturbances,  when  tiie  drops  may  be  discontinued 
for  a  time.  Muriate  of  pilocarpine  in  two  grain  solutions  may  be  used 
in  a  similar  manner  and  for  the  same  purpose;  but  it  contracts  the  pupil 
and  renders  the  accommodation  tense,  the  very  opposite  to  the  atropine 
effect.  I  have  not  much  confidence  in  this  remedy.  Powdered  calomel 
may  be  dusted  into  the  eye  every  second  day.  A  small  quantity  only 
should  be  used,  since  it  is  apt  to  collect  in  masses,  which  act  as  foreign 
bodies  (we  desire  to  produce  irritation  for  a  few  minutes  only).  A 
drachm  of  table  salt  to  a  pint  of  water  may  be  used  to  bathe  the  eyes 


TREATMENT.  151 

freely  four  or  five  times  a  day,  used  ■warm  or  cold  according  to  the 
patient's  pleasure,  though  warm  applications  are  more  likely  to  be  -well 
received.  Red  precipitate  ointment — Kj.  Vaseline,  5j;  hyd.  ox.  rub. 
in  very  fine  powder,  gr,  j  to  ij.  M. — placed  under  the  eyelids  every 
day  or  two,  is  often  very  beneficial.  Occasionally  the  ulcers  show  a 
disinclination  to  heal,  when  they  may  be  touched  with  Arg.  nit.,  gr. 
X,  aquae  dest.,  .5J.  M.  Wind  a  bit  of  absorbent  cotton  on  a  probe,  dip 
this  into  the  solution,  and  touch  the  ulcer,  but  no  other  point.  Cupri 
sulph.,  in  ten  grain  solutions,  may  be  used  for  the  same  purpose.  A 
protective  bandage  exerting  moderate  pressure  on  the  eye  sometimes 
does  good,  but  it  should  not  i'eA  uncomfortable.  If  tliere  be  much 
spasm  of  the  orbicularis,  however,  it  is  not  indicated.  If  the  pain  in 
the  eye  continue,  and  the  orbicularis  be  in  a  state  of  spasm,  a  cantho- 
lysis  may  be  done — that  is,  divide  the  external  canthus  so  as  to  cause 
the  lid  no  longer  to  press  hardly  upon  the  eyeball,  and  close  the  wound 
thus  made  by  stitching  the  skin  to  the  conjunctiva  above  and  below  the 
incision,  and  placing  one  stitch  in  the  extreme  outer  canthus.  This  ex- 
tends the  length  of  the  palpebral  opening.  The  result  of  the  operation 
is  temporarily  to  break  the  power  of  the  orbicularis,  so  as  to  arrest  the 
spasm.  This  measure  accomplishes  in  some  cases  what  nothing  else 
will. 

If  the  eye  be  painful,  Avithout  spasm  of  the  lid,  and  there  be  great 
photojjhobia,  whether  the  eyeball  be  too  hard  or  not,  paracentesis  may 
be  done.  The  mode  of  performance  is  described  in  the  treatment  of 
ophthalmia  neonati  in  another  place  in  this  book.  After  a  while  the 
accompiuiying  conjunctivitis  may  need  treatment  in  the  ordinary  way. 
Indeed,  astringents  may  often  be  used  quite  early  to  obviate  the  irri- 
tating effects  which  occasionally  result  from  the  use  of  atropine.  If  an 
ulcer  refuse  to  heal  after  the  treatment  already  laid  down,  iridectomy 
may  be  done,  though  this  is  not  often  resorted  to.  Occasionally  an 
ulcer  may  be  cut  across,  by  passing  a  narrow  Graefe's  knife  through  it, 
making  a  puncture  on  one  side  and  a  counter-puncture  on  the  opposite 
side,  and  ilien  cutting  out  quite  through  the  ulcer,  dividing  it  into  two 
equal  halves.  All  needful  treatment  for  the  constitutional  condition  of 
the  patient  should  be  attended  to.  So  necessary  are  fresh  air  and  sun- 
light that  I  would  never  shut  the  patient  in  a  dark  room.  Blue  or 
smoke-colored  glasses  may  be  worn  to  protect  the  eyes  from  a  strong 
light,  and  in  some  cases  the  eyes  may  be  protected  by  a  bandage  of 
some  dark  material,  so  that  the  ])atient  may  be  taken  for  an  airing  with- 
out sufl'ering.  I  wouM,  however,  atlvise  to  accustom  the  eyes  to  the 
light  as  much  as  ])ossible  without  causing  ])ain. 

In  parenchf/matous  or  diffuse  keratitis  we  have  quite  a  different 
array  of  symptoms.  The  margin  of  the  cornea  near  the  limbus  may 
show  a  decided  Z(me  of  injection  of  the  conjunctival  and  episcleral 
vessels.  It  may  be  so  excessive  as  to  consist  apjiarently  of  a  rosy  ring 
surrounding  the  cornea.  These  vessels  after  a  time  shoot  inward,  and 
may  involve  a  large  part,  or  even  the  whole  of  the  cornea.  In  other 
Cfises,  designated  non-vascular  diffuse  keratitis,  the  injection  is  very 
slight  indeed,  and  sometimes  apparently  wanting  altogether.  In  either 
case,  however,  the  same  conseipiences  result ;  tlie  cornea  bccomea  dif- 


152  STRUMOUS    OPHTHALMIA. 

fusely  clouded,  the  process  generally,  but  not  always,  commencing  at 
the  limbus.  This  cloudiness  may  be  quite  Avithout  lines  or  dots  of 
opacity,  like  ground  glass.  Again  it  may  appear  composed  of  innumer- 
able minute  opaque  points  or  lines  running  in  various  directions.  At 
first,  the  corneal  epithelium  escapes,  presenting  a  regular  and  uniform 
polish,  l)ut  afterward  it  becomes  opaque.  Again  if  the  process  involve 
the  whole  of  the  cornea,  minute  opaque  spots  may  be  seen  in  Descemet's 
membrane,  giving  it  some  of  the  characteristics  of  keratitis  punctata. 
In  the  earlier  stages  there  may  be  some  pain  and  intolerance  of  light, 
but  as  a  rule  the  disease,  for  a  corneal  affection,  is  comparatively  pain- 
less. Tlie  duration  of  tliis  disease  is  never  short;  it  may  continue  for 
many  months,  and  it  shows  a  strong  tendency  to  relapse.  The  most 
frequent  causes  are  hereditary  syphilis  and  struma.  Mr.  Hutchinson,  of 
London,  always  examines  the  teeth  of  these  patients  to  see  if  there  be 
anything  characteristic  of  hereditary  syphilis.  As  the  same  or  similar 
teeth  are  often  noticed  in  strongly  strumous  subjects,  it  becomes  doubly 
interesting  to  make  the  oljservation.  One  point  is  apparent  in  most  of 
these  cases,  that  there  are  in  almost  every  patient  some  signs  of  badly 
developed  physique — that  is,  f^iulty  tissue  elaboration.  As  a  rule,  both 
eyes  sooner  or  later  become  affected,  pointing  to  a  constitutional  origin 
of  the  affection. 

In  treatment  we  are  often  disappointed  in  our  efforts.  At  the  first, 
if  there  be  pain  or  photophobia,  atropine  may  be  instilled,  and  the  eyes 
bathed  with  warm  or  tepid  water,  several  times  a  day.  Tonics  or 
alteratives  are  always  indicated.  One  of  the  most  useful  prescriptions 
is  the  following : 

R. — Ilydrarg.  chlor.  corros.      .         .         .         .         .     gr.  j. 

Tine,  ciiichoii.  comp. 

Syr.  aurantii      .......     iiil  5iv. — Misce. 

Dose. — One  teaspoonful  three  times  daily  after  eating. 

Iodide  of  potassium  is  frequently  given,  and  may  very  properly  alter- 
nate with  tlie  mercurial ;  children  will  bear  very  large  doses  of  the 
iodide,  and  indeed  they  are  often  necessary  if  we  would  get  the  curative 
effects  of  the  drug ;  I  would  suggest  from  three  to  twenty  grains  three 
times  daily,  well  diluted  Avith  Avatcr.  Both  these  remedies  may  be  con- 
tinued for  months,  but  ptyalism  should  ahvays  be  avoided.  Cod-liver  oil 
Avith  extract  of  malt  may  be  administered.  Whatever  tends  to  im- 
prove the  patient's  general  condition  is  indicated.  Exercise  in  the 
fresh  air  is  good,  but  the  pernicious  effects  of  cold  must  be  avoided. 
Paracentesis  of  the  cornea  rarely  does  good,  but  occasionally  iridectomy 
mav  be  of  benefit.  The  complication  of  iritis  or  irido-choroiditis  is  not 
common,  though  it  does  occur.  When  the  disease  becomes  very  chronic 
there  Avill  be  hardly  vascularity  enough  for  the  purposes  of  repair.  This 
being  the  case,  stimulating  collyria  may  be  used,  similar  to  Avhat  is  indi- 
cated in  conjunctivitis.  Olive  oil  and  spirits  of  turpentine,  in  equal 
parts,  may  be  applied  to  the  eye  every  second  day.  Bathing  Avith  warm 
Avater,  sufficiently  to  congest  the  eye.  Avill  sometimes  be  serviceable.  An 
attack  of  acute  conjunctivitis  has  been  knoAvn  to  do  good.  But  do  Avhat 
we  may,  this  affection  sometimes  runs  on  unchecked  for  a  very  long 


TUBERCULOSIS.  153 

time.  From  some  recent  experiences  I  am  inclined  to  believe  that  bi- 
chloride of  mercury  internally  and  atropine  as  a  collyrium,  are  of  as 
much  value  as  any  other  agents  in  the  treatment  of  this  obstinate 
malady. 


CHAPTER  III. 

TUBERCULOSIS. 

The  term  tuberculosis  is  applied  to  a  disease  which  is  characterized 
by  the  formation  of  small  tubercles  or  nodules  in  one  or  more  organs. 
Though  more  prevalent  in  some  countries  or  localities  tluin  in  others,  it 
occurs  in  all  or  nearl}'  all  parts  of  the  globe,  from  which  we  have  exact 
information,  and  it  has  been  more  destructive  to  human  life  than  any 
other  one  disease. 

Etiology. — The  most  brilliant  discovery  of  the  last  decade  relating 
to  the  etiology  of  diseases,  is  that  of  the  specific  principle  of  tubercu- 
losis. It  has  long  been  suspected  by  observing  physicians  that  a  specific 
cause  did  exist,  and  that  this  disease  is  to  a  certain  extent  infectious, 
but  it  is  only  recently  that  patient  microscopic  investigations  have 
triumpiied  over  the  ditficulties  which  surround  this  subject,  and  have 
detected  the  microorganism  which  has  been  so  fatal  to  the  human  race. 
The  honor  of  discovery  belongs  mainly  to  Dr.  Koch,  of  Berlin.  In  his 
investigations  Koch  invariably  found  a  certain  bacillus  in  all  recent 
tubercles,  proving  beyond  a  doubt  that  they  ahvays  accompany  the 
development  of  the  tubercular  nodule.  By  inoculating  guinea-pigs, 
rabbits,  and  cats  with  tubercular  material  he  communicated  tuberculosis, 
reproducing  the  tubercular  nodule,  in  which  he  always  found  the  same 
bacillus.  But  it  still  remained  to  determine  the  relation  of  the  bacillus 
to  the  tubercle,  whether  it  was  merely  an  accidental  accompaniment,  or 
whether  it  sustained  a  causative  relation,  producing  the  nodule  by  its 
irritating  action  on  the  cellular  elements  of  the  part  where  it  hapi)ened 
to  lodge.  After  many  trials,  Koch  succeeded  in  pre))aring  a  jiabulum 
in  which  the  bacilli  grew  and  re|)roduce(l  their  kind,  liy  adding  a 
little  of  the  first  cultivation  to  the  jtabidum,  he  j)roduced  a  second 
cultivation,  and  after  a  series  of  cultivations  he  produced  a  bacillus 
which  was  evidently  freed  from  nil  other  substances.  With  the  bacillus 
of  the  last  cultivation  he  was  able  to  produce  the  tubercular  nodule, 
having  all  the  characteristics  which  are  observed  when  it  is  developed 
in  the  usual  way  in  man.  Different  microfirganisms  take  coloration 
differently,  and  Koch  was  enabled  to  discriminate  the  tubercular  bacillus 
under  all  circumstances  from  other  microbes  by  the  peculiar  color  im- 
J)arted  to  it. 

The  tubercle  bacilli  have  the  form  of  "delicate  rods,  from  a  (juarter 
to  half  the  diameter  of  a  blood  corpuscle  in  length.'     The  more  severe 


154  TUBERCULOSIS. 

the  tuberculosis,  tlie  greater  the  number  of  bacilli.  They  occur  not 
only  in  the  recent  tubercle,  but  also  in  immense  numbers  in  the  peri- 
phery of  the  caseous  masses  of  a  tubercular  patient.  They  are  found 
not  only  elsewhere,  but  also  in  the  interior  of  the  giant  cells,  as  many 
as  twenty  even  in  some  cells.  They  do  not  seem  to  have  the  power  of 
movement,  and  oval  spores  are  found  in  some  of  them.  They  grow  in 
a  temperature  of  8G°  F.  to  104°  F.,  and  not  in  a  temperature  outside 
these  limits. 

As  might  be  expected,  these  microscopical  researches  of  Koch  have 
attracted  wide  attention,  and  have  led  to  a  repetition  of  his  experiments 
by  many  pathologists,  and  to  new  experiments  relating  to  tlie  etiology 
of  tuberculosis.  The  result  has  been  to  estabhsh  more  firmly  the  views 
of  Koch,  and  the  doctrine  that  tuberculosis  is  a  specific  disease,  and  that 
the  bacillus  is  the  specific  principle,  appears  to  be  fully  established. 

Amoni!;  the  most  thorough  and  convincins;  researches  bearino;  on  the 
causative  relation  of  microorganisms  to  tuberculosis,  growing  out  of 
Koch's  discovery,  "were  those  contained  in  a  report  to  the  London  Asso- 
ciation for  the  Advancement  of  Medicine  by  Research  {Practitioner, 
London  Lancet,  March  17,  1883).  Experiments  were  made  with  the 
cultivated  bacilli  obtained  from  Koch.  "Twelve  animals  were  inocu- 
lated with  these  organisms,  chiefly  into  the  anterior  chamber  of  the  eye, 
and  all  of  them  became  tuberculous,  and  that  more  rapidly  than  after 
inoculation  of  tuberculous  material.  The  tubercles  produced  in  these 
cases  Avei'e  infective,  and  caused  tuberculosis  in  other  animals.  On 
examination  of  tuberculous  material,  Koch's  tubercle  bacilli  are  always 
found,  though  in  varying  numbers.  .  .  .  About  eighty  organs  of 
tuberculous  animals  and  thirty- six  cases  of  human  tuberculosis  were 
examined,  and  in  all  of  these,  without  exception,  tubercle  bacilli  were 
found." 

The  discovery  of  Koch  has  already  proved  of  great  importance  as  an 
aid  in  diagnosis,  for  the  sputum  of  tubercular  patients  contains  the 
bacillus.  Tubercular  sputum  affords  a  soil  in  which  the  bacillus  thrives 
and  multiplies,  as  it  does  in  the  tissues  of  a  tubercular  patient,  and  by 
careful  microscopic  examination  we  are  able  to  discover  it  in  this 
sputum,  while  it  is  absent  from  non-tubercular  sputum.  Accoi'ding  to 
Frisch  {Wiener  med.  Woch.,  No.  4G,  1883),  the  bacilli  were  found 
without  an  exception  in  the  sputum  of  140  patients  with  confirmed 
tuberculosis,  while  the  sputum  of  150  non-tubercular  patients  was  in 
every  instance  free  from  them.  Heitler  (  Wiener  med.  Woch.,  No.  43, 
1883)  examined  the  sputum  of  140  tubercular  patients,  one  of  Avliom 
had  miliary  tubercles,  and  one  other  caseous  ])neumonia.  All  the  other 
cases  were  chronic  and  were  grouped  by  the  author  as  follows  :  1st.  Six 
cases  of  old  infiltration  of  the  apices  of  the  lungs,  cured  with  the  per- 
sistence of  dulness  on  percussion,  without  rales.  No  bacilli  observed. 
2d.  Twelve  cases  of  tuberculosis  with  slight  dulness  and  dry  rales. 
In  two  of  these,  notwithstanding  marked  physical  signs,  fever  was 
absent,  and  the  tubercular  process  was  arrested  apparently  ;  no  bacilli. 
In  the  sputum  of  the  remaining  ten  cases,  bacilli  were  present  in  all 
the  examinations  except  two.  The  tiiird  group  contained  cases  of 
advanced  and  progressive  tuberculosis,  and  the  fourth  group  cases  of 


ANATOMICAL    CHARACTERS.  155 

advanced  chronic  phthisis  but  with  remissions.  In  the  sputum  of  these 
two  groups,  bacilli  were  always  observed.  That  Ileitler,  in  six  in- 
stances, witnessed  the  disappearance  of  bacilli  Avhen  the  tubercular 
process  was  arrested,  is  an  interesting  fact,  as  showing  the  relation 
of  the  bacilli  to  tuberculosis.  He  examined  the  sputum  of  twenty-nine 
non-tubercular  patients,  patients  with  pneumonia,  bronchitis,  bronchial 
dilatation,  anil  putrid  bronchitis  Avith  gangrene,  and  in  no  instance 
found  the  bacilli  of  tuberculosis. 

As  usually  happens  when  a  great  discovery  is  announced,  there  are 
dissentients;  there  are  those  apparently  competent  to  express  an 
opinion,  as  Spina  and  Formad,  who  do  not  accept,  or  only  partly 
accept  the  views  of  Koch.  But  the  testimony  of  many  observers,  con- 
stantly accumulating,  tends  to  establish  more  securely  the  doctrine  of 
the  parasitic  origin  of  tuberciilosis,  and  it  is  noAV  apparently  as  securely 
established  as  most  doctrines  in  pathology. 

Kochs  discovery  necessitated  revision  of  the  teachings  long  accepted, 
relating  to  tuberculosis.  The  tubercular  nodule  is,  as  we  will  see,  an  ao^- 
gregation  of  cells,  produced  from  the  cellular  elenients  of  the  [lart  where 
the  nodule  ajjpcars  through  a  proliferating  jjrocess,  caused  by  an  irri- 
tant, and  in  the  light  of  our  present  knowledge  we  consider  the  bacillus 
to  be  the  irritant.  A  local  corpusculation,  and  a  cellular  nodule  may 
be  produced  in  the  lungs  or  elsewhere  by  the  lodgement  of  a  non-specific 
irritant,  whether  organic  or  inorganic,  as  putrid  cheese,  particles  of 
dust,  or  metallic  particles,  and  thus  far  no  cells  have  been  discovered 
in  nodules  thus  produced,  which  are  characteristic  of  tuberculosis.  The 
giant  cells  which  at  one  time  were  thought  to  be  peculiar  to  the  tuber- 
cular nodule,  have  been  found  in  growths  of  another  nature,  as  in  gum- 
mata.  The  characteristic  and  peculiar  element  in  the  tubercular  nodule 
is  the  bacillus. 

It  has  long  been  the  belief  from  clinical  observations,  in  Southern 
Euroj)e,  and  of  certain  observing  physicians  in  the  temperate  regions  of 
Europe  and  America  that  phthisis  is  contagious,  and  the  acceptance  of 
the  parasitic  theory  will  probably  soon  render  this  belief  an  established 
principle  in  pathology.  Already  many  instances  liave  been  published 
in  the  journals  which  appear  to  show  the  infectiousness  of  tuberculosis, 
as  the  following  :  In  an  inland  town  in  p]urope,  a  midwife  Avith  a<lvanced 
phthisis,  had  been  in  the  habit  of  bloAving  into  the  nu)utlis  of  new- 
born infants,  and  so  many  of  them  perished  of  tubercular  disease,  as  to 
e.xcite  attention  and  cause  alarm,  Avhile  those  attended  by  a  liealthy  mid- 
Avife  remained  Avell.  Dr.  E.  I.  Keinpf  relates  the  followirvg  striking 
example  in  the  Louisville  Medical  News  for  March  22,  1(S!S4:  In  the 
fall  of  18Sf),  a  girl  of  eighteorj  years,  avIiosc  brother  had  died  of  con- 
sumption, was  found  to  have  tub(M-cles  at  the  aj)ices  of  both  lungs.  She 
.slept  in  the  general  dormitory  with  the  other  sisters,  and  in  four  months 
nine  of  her  companions  began  to  cough,  and  Averc  found  to  have  tuber- 
cles. No  one  of  the  sisterhood  iiad  previously  iiad  disease  of  this  kind. 
The  fact  that  wives  devoted  in  their  attendance  on  consumptive  husbands, 
fre([ueritly  perished  of  the  saum  disease,  physicians  in  various  countries 
have  long  remarki'(l,  but  it  ha-;  usually  been  atri-ibutt'(l  to  the  (h'presse(\ 
Btate  of  system  incident  to  long  Avatching  and  grief,  and  not  to  any 


156  TUBERCULOSIS. 

contagious  property.  But  now  that  a  clearer  insight  has  been  obtained 
into  the  nature  of  tuberculosis,  and  both  microscopical  researches  and 
clinical  facts  indicate  its  comniunicability,  more  caution  will  be  excTcised 
in  the  intercourse  with  patients. 

The  causati\'e  relation  of  scrofula  to  tuberculosis  Ave  have  considered 
elsewhere,  but  we  may  here  repeat  that  scrofulous  ailments,  especially 
the  caseous  products,  aflbrd  the  soil  which  is  favorable  to  the  growth 
and  multiplication  of  the  bacilli.  Hence  these  microbes  are  not  infre- 
quently found  in  scrofulous  products,  showing  that  the  tubercular  has 
supervened  on  the  scrofulous  disease.  Kanzler  treats  of  the  relation  of 
scrofula  to  tuberculosis,  in  the  Berlin,  klin.  Wocli.,  January  14,  1884. 
He  believes  that  the  two  diseases  are  distinct,  but  that,  as  expressed  by 
the  French  reviewer,  la  scrofule  offre  un  terrain  de  predilection  pour 
le  dcveloppemenl  de  la  tuberculose.  He  has  discovered  bacilli  only  in 
a  minority  of  the  local  manifestations  of  scrofula,  never  in  glands  which 
had  not  undergone  suppuration  or  caseation,  never  in  eczema,  impetigo, 
suj)purative  otitis  medi;i,  and  never  in  the  nasal,  conjunctival,  ]jharyngeal, 
and  vaginal  catarrhs  of  the  scrofulous.  It  is  not  till  degenerative  changes 
have  occurred  in  the  inflammatory  products  of  scrofula,  that  the  bacilli 
of  tuberculosis  appear,  indicating  the  supervention  of  the  latter  disease. 

Anatomical  Characters  of  the  Tubercle. — As  Virchow  pointed 
out,  the  tubercular  nodule  when  recent,  is  semi-translucent  and  small, 
attaining  about  the  size  of  a  millet  seed,  and  consisting  mainly  of  cells. 
The  cells  which  he  considers  characteristic  of  tubercle,  and  of  which  it 
is  chiefly  composed,  resemble  the  white  corpuscles  of  the  blood  in  appear- 
ance and  size,  but  some  are  smaller,  and  others  larger  than  those  cor- 
puscles. They  have  been  designated  the  lymphoid  cells.  Each  cell 
when  fully  developed,  has  a  bright  homogeneous  nucleus,  snuill  and 
spherical,  or  large  and  oval,  and  nucleoli.  A  large  cell  sometimes  con- 
tains two  or  more  nuclei.  The  lymphoid  cells  appear  to  be  developed 
from  the  cellular  element  of  the  connective  tissue.  This  is  Virchow's 
belief.  In  addition  to  these  cells,  which  constitute  the  greater  part  of 
the  tubercle,  large  uninuclear  cells  are  also  observed,  designated  ejjithc- 
lioid  cells.  They  resemble  large  and  swollen  endothelial  or  epithelial 
cells,  and  they  are  believed  by  pathologists  to  be  produced  from  these 
cells,  which  lie  within  the  area  of  the  nodule.  A  third  cell  also  occurs, 
known  as  the  giant  cell,  from  its  size.  It  has  many  nuclei,  and  oc- 
cupies chiefly  the  central  part  of  the  nodule.  All  these  cells,  as  has 
been  recently  shown,  occur  in  other  pathological  products,  besides  the 
tubercular  nodule,  and  no  one  of  them  is  therefore  characteristic  of  it. 
But  the  element  which  is  of  greatest  importance,  since  it  sustains  a  cau- 
sative relation  to  the  disease,  was,  as  we  have  seen,  the  last  discovered. 
The  bacillus  is.  always  found  in  the  recent  tubercle  lying  without  the 
cells,  as  we  have  stated,  but  also  in  the  interior  of  the  giant  cells,  for 
which  it  appears  to  have  an  affinity.  A  fibrous  network  with  more  or 
fewer  bloodve.ssels,  surrounds  the  cells  and  hoMs  them  together.  The 
bloodvessels  belong  to  the  normal  tissues  and  are  not  a  new  growth,  the 
tubercle  having  devclo])ed  around  them.  The  tubercles  are  single,  or  in 
clusters,  forming  ma.sses  of  considerable  size. 

When  the  tubercle  has  attained  a  certain  age,  caseation  always  occur 


n 

1 


ANATOMICAL    CHARACTERS.  157 

in  its  centre  and  extends  outward,  causing  an  opaque  and  yellowish- 
■\vhite  dead  mass,  in  whicli  frao;mentary  cells  can  be  observed  under  the 
microscope.  Caseation  is  now  known  to  be  a  form  of  decay  which  is 
common  to  patholoirical  products  of  difterent  kinds,  and  is  not  peculiar 
to  tuberculosis,  as  was  supposed  before  the  time  of  Virchow.  It  occurs 
in  consequence  of  abundant  exudation  or  cell  formation,  and  the  com- 
pression and  obliteration  of  vessels.  It  is,  therefore,  more  common  in 
scrofula  than  in  any  other  disease,  since  scrofulous  inflammations  aiford 
the  conditions  in  which  it  is  especially  apt  to  occur.  The  yellow 
tubercle  is,  therefore,  only  an  advanced  stage  of  the  semi-transparent  or 
miliary  tubercle.  In  the  cheesy  metamorphosis  granules  of  fat  are 
deposited  within  and  around  the  cells,  and  the  cells  shrivel  and  disinte- 
grate. These  shrunken  granular  and  fragmentary  cells  were  believed 
to  be  the  true  tubercular  cells  until  A^irchoAV  pointed  out  their  true 
character.  When  the  tuljercle  or  tlie  tubercular  mass  becomes  yellow  or 
caseous,  and  circulation  ceases  in  it,  it  is  surrounded  by  a  vascular  zone 
in  which  circulation  still  continues.  It  is  very  seldom,  perhaps  never, 
absorbed,  although  particles  of  it  may  enter  the  .lymphatics  or  blood- 
vessels, and  be  carried  elsewhere  with  the  bacilli.  It  is  an  irritant, 
producing  inflammation  in  the  surrounding  tissues,  with  thickening, 
induration,  and  abundant  production  of  pus  cells,  Avhich  mingle  with  the 
elements  of  the  tubercle.  Its  history  henceforth  is  tluit  of  an  abscess, 
and  ulceration  and  discharge  of  the  liquefied  substance  upon  one  of  the 
free  surfaces  is  the  common  result.  In  rare  instances  the  tubercle, 
mstead  of  cheesy  degeneration,  undergoes  fibroid  degeneration  or  crete- 
faction. 

Various  pathological  conditions  furnish  the  soil  in  whieli  the  bacillus 
obtains  lodgement  and  grows,  and  in  this  way  becomes  a  cause  of  tuber- 
culosis. Olieesy  pneumonia  is  not  an  infrequent  cause  of  tuberculosis, 
and  so  are  exhausting  suppurations.  During  epidemics  of  measles 
many  cases  occur  of  cheesy  pneumonia  ending  in  tuberculosis.  Cheesy 
and  disintegrating  lymphatic  glands,  as  the  bronchial,  often  also  lead  to 
tuberculosis. 

Anatomical  Characters  in  Infancy  and  Childhood. — The  ana- 
tomical characters  of  tuberculosis  in  the  first  years  of  life  vary  in  certain 
particulars  from  the  form  which  they  present  in  the  adult,  but  after  the 
age  of  three  years  the  differences  are  fewer  and  less  pronounced  than 
previously. 

TubcrfUiar  laryngitis,  so  common  in  the  adult,  is  absent  in  a  large 
pro})ortion  of  cases  under  the  age  of  three  years,  and  when  present  it 
has  little  intensity.  Ulceration  of  the  larynx  very  seldom  occurs.  This 
has  been  attributed  to  the  fact  that  there  is  so  little  expectoration  in 
young  children,  the  sputum  being  an  irritant.  Niemeyer,  however,  does 
not  consider  the  sputum  of  tuberculosis  sufficiently  irritating  to  cause 
laryngitis  and  laryngeal -ulcvration  ;  but  the  arguments  in  fivor  of  this 
mode  of  causation,  in  my  opinion,  inore  than  counterbalance  those  Avhich 
have  been  presented  against  it. 

I  have  never  met  a  case  of  tubercular  ulceration  of  the  larynx  or 
trachea  in  the  post-mortem  examination  of  young  children,  nor  do  [ 
recollect  ever  treating  a  case  in  which  there  was  that  degree  of  dysphouiu 


158  TUBERCULOSIS. 

which  indicated  ulceration.  Rilliet  and  Barthez,  in  more  than  300 
necropsies  of  tubercuhir  cases,  found  no  ulcers  in  the  larynx  or  trachea 
under  the  age  of  three  years  ;  but  met  8  cases  between  the  ages  of  three 
and  ten  years,  and  8  between  ten  and  fourteen  years.  The  ulcers, 
■whether  seated  in  the  larynx  or  in  the  trachea — and  they  are  in  most 
cases  in  the  former,  since  the  inequalities  upon  the  surface  of  the  larynx 
fjivor  the  retention  of  the  sputum — are  commonly  small,  superficial, 
round  or  elongated,  and  with  little  thickening  or  infiltration  of  their 
borders.  Occurring  in  the  folds  of  the  mucous  membrane,  as,  for  ex- 
ample, around  the  vocal  cords,  their  form  is  usually  elongated. 

Bronchitis  is  not  infrequent.  This  inflammation  is  due  to,  and  de- 
pendent on,  the  pulmonary  tubercles,  and  is  therefore  most  intense  in 
the  part  of  the  lung  where  the  tubercles  are  most  abundant  and  furthest 
advanced.  Consequently  it  is  more  mtense  on  one  side  than  on  the 
other,  and  it  may  be  unilateral.  It  difl'ers  in  this  respect  from  idio- 
pathic bronchitis,  which  is  commonly  pretty  uniform  on  the  two  sides. 
It  differs  also  in  the  fact  that  it  is  sometimes  accompanied  by  ulcerations. 
The  ulcers  are  round  or  elongated  in  the  direction  of  the  axes  of  the 
tubes,  and,  like  those  of  the  larynx  or  trachea,  are  superficial.  Idiopathic 
bronchitis  of  infmcy  and  childhood  does  not  cause  ulceration.  Circum- 
scribed inflammation  may  attack  a  bronchial  tube,  as,  indeed,  the 
trachea,  and  give  rise  to  ulceration  and  perforation,  from  fhe  presence 
and  pressure  of  a  diseased  lymphatic  gland  external  to  the  tube.  This 
subject  will  be  treated  of  hereafter. 

Lungs. — It  is  well  known  that  in  the  adult,  tubercles  are  always 
present  in  the  lungs,  if  they  occur  in  any  part  of  the  system.  I  have 
met  two  cases  in  which  the  lungs  were  free  from  tubercles  in  30)  post- 
mortem examinations  of  children  wlio  died  of  tuberculosis.  One  of  the 
two  Avas  an  infant,  but  its  exact  age  is  not  stated  m  the  records.  It  had 
cheesy  degeneration  of  the  thymus  and  bronchial  glands,  enlargement  of 
the  mesenteric  glands,  but  without  cheesy  degeneration,  and  disseminated 
tubercles  in  liver  and  spleen.  The  other,  fifteen  months  old  at  death, 
had  tubercular  meningitis,  with  numerous  granulations  upon  the  con- 
vexity of  the  brain,  and  the  other  usual  lesions  of  meningeal  inflamma- 
tion, with  bronchial  and  mesenteric  ghinds  slightly  enlarged  and  cheesy, 
and  one  of  the  former  softened.  In  one  case,  then,  in  18,  the  lungs 
had  escaped  the  disease,  llilliet  and  Barthez  state  that  they  found  the 
lungs  non-tubercular  in  47  cases  in  312,  and  Hiller  did  in  25  cases  in 
160.  In  their  cases,  therefore,  tlic  lungs  were  exempt  from  tubercles  in 
about  1  case  in  7.  But  it  is  to  be  recollected  that  the  statistics  of  these 
observers  were  prepared  at  the  time  when  all  cheesy  degenerations  were 
thought  to  be  tubercular,  and  the  bronchial  and  mesenteric  glands  are 
sometimes  cheesy  when  there  are  no  tubercles  or  lesions  referable  to 
tuberculosis  in  any  other  part  of  the  system.  I  have  records  of  two 
such  cases,  Avhich  I  reject  from  my  statistics  of  tuberculosis,  as  there  is 
no  evidence  that  the  disease  was  anything  else  than  cheesy  inflamma- 
tion. Did  I  include  these  cases,  my  statistics  would  more  closely 
correspond  Avith  theirs. 

Pulmonary  tubercles  in  children  under  the  age  of  three  years  are,  as 
a  rule,  discrete,  and  disseminated  through  the  lungs.     In  cases  at  this 


LUNGS.  159 

ac'e,  which  have  advanced  to  a  fatal  termination,  we  find  yellow  tubercles 
from  the  size  of  a  pin's  head  to  that  of  a  shot  in  the  different  lobes ; 
many  still  semi-transparent  if  the  disease  have  been  of  short  duration, 
but  if  protracted  most  of  them  yellow,  and  here  and  there  one  softened 
and  .surrounded  by  condensed  fibrous  tissue.  Around  the  semi-trans- 
parent or  gray  tubercles,  many  of  which  were  growing,  and  therefore 
were  in  the  state  of  active  cell  proliferation  at  the  time  of  death, 
narrow  vascular  zones  can  often  be  detected  by  the  naked  eye. 

Under  the  age  of  three  years,  tuberculosis  exhibits  but  little  tendency, 
perhaps  none,  to  aifect  the  upper  lobes  sooner  or  in  greater  degree  than 
the  lower. 

The  following  are  the  statistics  relating  to  the  site  of  the  tubercles  in 
the  lunjis  in  the  cases  which  I  have  examined.  All,  it  is  to  be  remem- 
bered,  were  under  the  age  of  three  years : 


Tubercles  disseminated  throughout  the  lungs        .         .         ,         .26 

Tubercles  disseminated  throughout  the  two  upper  lobes  .  .  3 
Tubercles  disseminated  through  right  middle  lobe  and  left  lower 

lobe  only     ...........  1 

Tubercles  disseminated  through  left  upper  lobe  on!}'  ...  2 
Tubercles  disseminated  (few  and  semi-transparent)  in  left  lung 

only     ............  1 

Tubercles  disseminated  in  three  points  in  right,  and  two  in  left 

lung 1 

No  tubercles  in  Ijngs      .........  2 

3(5 

Between  the  ages  of  three  and  fifteen  years,  statistics  show  that  the 
upper  lobes  are  more  liable  to  tubercles  than  the  lower ;  but  the  differ- 
ence in  liability  is  not  great.  In  many  cases  occurring  in  this  period, 
the  different  lobes  are  affected  nearly  simultaneously,  and  not  very  in- 
frequently the  upper  lobe  is  the  last  which  is  involved.  In  October, 
1866,  I  made  the  post-mortem  examination  of  a  boy  who  died  in  the 
Children's  Service  of  Charity  Hospital,  at  the  age  of  fifteen  years,  and 
small  scattered  tubercles  were  found  in  the  lower  lobe  of  the  left  lung, 
while  all  other  portions  of  these  organs  were  healthy.  Killiet  and 
Barthez,  who  include  in  the  same  statistics  all  cases  from  birth  to  the 
age  of  fifteen  years,  found  gray  semi-transparent  tubercles 

Cases, 
In  the  right  superior  lobe  in  .         .         .         .         .         .         .         .03 

In  the  right  middle  lobe  in    ........     43 

111  the  right  lower  lobe  in      ........     65 

In  the  left  superior  lobe  in     .         .         .         .         .         .         .         .65 

In  the  left  inferior  lobe  in      ........     54 

The  same  observers  found  yellow  tubercles  in  the 

Right  su[)Crior  lobe  in 40 

Right  middle  lobe  in      .         . 28 

Right  inferior  lobe  in  .          ........     39 

Left  superior  lobe  in  .         .         .         .         .         .         .         .         .35 

Left  inferior  lobe  in  .........     31 

Tubercle,  especially  when  softening  commences,  is  itself  an  irritant, 
exciting  inliammation  aroun<l  it.     Inflammation  occurrinff  froiu  this  cause 


IGO  TUBERCULOSIS. 

is  obviously  likely  to  be  protracted,  continuing  for  weeks  or  months, 
unless  the  tubercular  matter  bo  eliminated  by  ulceration.  The  highly 
vascular  and  delicate  lungs  of  the  young  child  are  very  liable  to  iniiam- 
mation  Avhen  they  are  the  seat  of  tubercles,  and  as  the  tubercles  are 
disseminated,  the  pneumonia  is  commonly  more  extensive  than  when  it 
occurs  from  ordinary  causes.  In  fifteen,  or  nearly  one-half  of  my  cases, 
there  was  pneumonia  aft'ecting  portions  of  one  or  more  lobes,  or  an  entire 
lobe.  From  tbe  extent  and  position  of  the  solidified  portions,  it  was 
obvious  that  in  most  instances  the  inflammation  originated  from  the 
irritating  effect  of  the  tubercular  matter,  while  in  others  it  was  due  to 
hypostatic  congestion,  occurring  in  consequence  of  the  long-continued 
recumbent  position  and  feebleness  of  circulation.  In  these  fifteen  cases 
the  seat  and  extent  of  the  inflammation  were  as  follows : 

Cases. 
Nearly  entire  right  luntj  i         ........     2 

Nearly  entire  middle  and  lower  lobe        ......     1 

Entire  left  upper  lobe       .........     2 

A  considerable  part  of  both  lun^s 1 

Posterior  parts  of  both  lower  lobes  .......     4 

Posterior  part  of  left  lung        ........     1 

Left  lower  lobe,  and  right  middle  and  lower  lobes  ...         .1 

Left  upper  lobe  (contained  a  large  cavity)  and  posterior  part  of  left 
lower  lobe     ...........     1 

Nodules  of  inflamed  lung  around  tubercles      .         .         .         .         .2 

The  inflammation  in  about  one-third  of  the  cases  was  due  to  hypo- 
stasis, since  it  occurred  in  depending  portions,  extended  but  little  into  the 
lungs,  and  sustained  no  relation  to  the  amount  of  tubercle.  It  was  in 
the  stage  of  red  or,  more  rarely,  of  gray  hepatization. 

In  seven  of  the  cases  tliere  Avere  pulmonary  cavities  as  large  in  pro- 
portion as  we  ordinarily  find  in  tuberculosis  of  the  adult.  The  seat  of 
one  was  in  the  right  lower  lobe ;  of  two,  the  left  upper  lobe ;  of  one, 
the  right  upper  lobe;  of  another,  the  right  lung,  its  exact  seat  not  stated; 
and  in  the  remaining  case  the  cavity,  which  Avas  the  largest  of  all,  occu- 
pied the  interior  of  all  three  lobes  on  the  right  side.  Some  idea  of  the 
size  of  these  cavities  may  be  learned  by  the  following  extracts  from  the 
records:  1st  Case.  "A  small  superficial  cavity  communicating  on  one 
side  with  a  bronchial  tube,  and  on  the  other  side  with  a  smjill  circum- 
scribed collection  of  pus  in  the  pleural  cavity."  2d  Case.  "Cavity  of 
the  size  of  a  hickory-nut."  3d  Case.  "Cavity  of  the  size  of  a  large 
hickory-nut."  4th  Case.  ."Cavity  three-fourths  of  an  inch  in  diameter." 
5th  Case.  "A  large  abscess."  Gth  Case.  "The  cavity  occupied  nearly 
the  whole  of  the  interior  of  the  left  upper  lobe."  7th  Case.  "About 
half  the  right  lung  excavated  into  a  cavity  which  extended  through  the 
three  lobes." 

Circumscribed  pleuritis,  produced  by  tubercles  underneath  the  pleura, 
was  observed  in  seven  cases.  It  was  ordinarily  attended  by  little  exuda- 
tion except  the  fibrin,  but  in  one  case  a  sufficient  amount  of  serum  had 
been  exuded  to  compress  considerably  the  lung.  I*us  was  not  observed 
in  any  notable  quantity. 

Emphysema  was  present  in  several  cases,  chiefly  in  the  upper  lobes, 
sometimes  vesicular,  with  fulness  or  bulging  of  the  lung,  an  anaemic 


LUNGS.  161 

appearance  of  it,  and  doughy,  inelastic  feel.  In  other  cases  emphysema 
■was  interstitial,  producing  little  bladders  of  air  under  the  pleura,  espe- 
cially toward  the  root  of  the  lung,  or  separating  the  lobules  by  wedge- 
shaped  or  irregular  interspaces  filled  with  air.  In  one  case  air  had 
escaped  from  an  emphysematous  bladder  into  the  right  pleural  cavity, 
causing  pneumothorax  and  collapse  of  the  lung. 

Xext  to  the  lungs,  the  bronchial  glands  are  more  frequently  diseased 
than  any  other  organs,  in  the  tuberculosis  of  infancy  and  childhood." 
They  undergo  the  successive  structural  changes  which  characterize 
glandular  infiammations,  namely,  hyperplasia,  and  more  or  fewer  of  them 
cheesy  degeneration  and  softening.  In  the  state  of  hyperplasia  their 
firmness  is  diminished,  and  they  have  a  pale  flesh-color.  Cheesy  degen- 
eration commences  in  one  or  more  points  in  the  gland,  sometimes  in 
the  peripheral,  sometimes  in  .the  central  portion,  and  it  extends  till  the 
whole  gland  presents  the  well-known  cheesy  appearance.  A\  hen  the 
gland  softens,  the  thick  liquid  has  a  puriform  appearance,  consisting 
of  amorphous  matter,  fiitty  particles,  and  the  shrivelled  and  disin- 
tegrated cells  of  the  gland.  Soon  pus-cells  occur,  and  their  number 
increases. 

Rilliet  and  Barthez  state  that  the  bronchial  glands  were  tubercular 
in  249  cases  in  children,  while  the  lungs  were  tubercular  in  265.  All 
cheesy  glands,  it  is  to  be  recollected,  they  considered  tubercular.  In  4 
of  the  36  cases  which  I  have  examined,  no  record  was  preserved  of  the 
state  of  the  bronchial  glands;  in  one  case  there  Avas  no  perceptible 
hyperplasia  and  no  cheesy  degeneration;  in  two  there  was  hyperplasia, 
but  no  cheesy  degeneration,  while  in  the  remaining  twenty-nine  cases 
there  was  cheesy  degeneration  of  more  or  fewer  of  the  enlarged  glands, 
or  parts  of  them,  with  occasional  softening.  In  the  fact  that  the 
bronchial  glands  are  enlarged  and  caseous,  we  liave  an  explanation  in 
part  of  the  fact,  that  the  symptoms  in  the  tuberculosis  of  young  children 
differ  from  those  in  the  adult,  since  Louis  found  the  bronchial  glands 
involved  in  only  twenty-eight  per  cent,  of  the  adult  cases  of  tuberculosis 
which  he  examined,  and  Lombard  in  only  nine  per  cent.  A  gland 
pressing  upon  the  recurrent  laryngeal  or  pneumogastric  nerve,  or  the 
trachea,  may  give  rise  to  dyspnoea  and  a  cough ;  or  on  the  descending 
vena  cava  or  one  of  the  ven?e  innominatje,  to  congestion  of  the  brain 
and  meninges,  intracranial  serous  effusion,  and  even  thrombosis  in  the 
cranial  sinuses.  That  a  softened  bronchial  gland  is  not  infrequently 
eliminated  from  the  system,  by  ulceration,  into  a  bronchial  tube  or  into 
the  trachea,  is  well  known.  In  one  case  which  I  observed  the  ulcer- 
ation had  destroyed  portions  of  three  of  the  cartilaginous   rings  of  a 

'  The  term  bronchial  phthisis  ha-  long  been  applied  to  that  state  in  which 
the  bronchial  inlands  ar»  eiiiari^ed  and  cheesy.  Now  this  fjliindular  disease,  we 
have  seen,  is  often  the  result  of  inflammation  in  the  strumous;  ami  while  it  ma}'  he 
the  cause  of  tubercular  infection,  is  pr.)bably  n-t,  in  most  instances,  tubercular 
itself.  But  microscopy  has  not  yet  drawn  ihe  distinction  between  the  cells  of 
lymphatic  inlands,  which  cause  the  enhir<,'oment  by  |)roiiferation  when  the  ^hmds 
are  inflamed,  and  the  cells  <>f  the  tubercular  neoplasm.  They  appear  alike  in  the 
Held  of  the  microscope.  Therefore  it  seems  proper  not  to  atlem|.t  to  (iisliniruish 
scrofuldus  glands  from  tubercular,  when  they  occur  in  a  patient  allected  by 
tuberculosis. 

11 


162  TUBERCULOSIS. 

bronchus,  and  the  aperture  was  plugged  by  a  cheesy  fragment  of  a 
softened  ghind  which  protruded.  Occasionally,  it  is  stated  by  authors, 
the  ulceration  is  into  one  of  the  large  vessels  of  the  mediastinum,  or 
even  into  the  oesophagus. 

The  following  is  an  example  of  bronchiul  phthisis,  as  it  commonly 
occurs.  This  case,  Avhich  is  not  included  in  the  foregoing  statistics,  was 
seen  almost  daily  by  me  during  its  entire  progress.  On  September  3, 
1874,  I  examined  an  infant  in  the  New  York  Infant  Asylum,  who  had 
wheezing  respiration  during  the  last  eight  days.  The  wheezing  occurred 
both  on  inspiration  and  expiration,  and  also,  though  less  pronounced, 
during  sleep;  pulse  9(3,  respiration  40,  temperature  normal.  Its  mother, 
Avho  had  charge  of  it,  and  had  till  recently  wet-nursed  it,  had  une- 
quivocal symptoms  of  tuberculosis  for  several  months.  The  child  was 
pallid,  and  its  flesh  was  soft  and  flabby.  The  fauces  were  perhaps  a 
little  redder  than  usual,  but  were  otherwise  normal,  and  a  careful  ex- 
ploration of  the  chest  revealed  no  cause  of  the  embarrassed  respiration. 
Auscultation  and  percussion  gave  a  negative  result.  In  the  latter  part 
of  September  a  troublesome  diarrhoea  occurred,  Avhich  continued  more 
or  less  till  near  death.  The  temperature  on  September  28th,  October 
8th,  10th,  and  11th,  was  100^°,  100°,  99|,  and  100°.  The  pulse  on 
October  10th  and  11th  was  120  and  126.     On  October  8th  the  per- 

FiG.  20. 


^..BCipiji^; 


cussion-sound  over  the  upper  part  of  the  right  lung  seemed  somewhat 
duller  than  on  the  other  side,  though  the  respiration  was  not  observed 
to  be  notably  changed  in  the  area  of  the  dulness.  There  Avas  but  little 
cough  durin"'  the  entire  sickness.  Death  occurred  on  October  20th. 
At  the  autopsy  the  bronchial  glands  were  found  enlarged  and  cheesy, 
and  underneath  the  right  bronchus,  near  the  bifurcation,  Avas  a  softened, 
almost  diffluent  gland,  as  large  as  a  small  hickory-nut,  and  compressing 
the  bronchus.  This,  no  doubt,  had  produced  the  wheezing  respiration, 
Avhich  had  been  the  chief  local  symptom.  The  lungs,  spleen,  and  in  less 
degree  the  liver,  contained  numerous  small  miliary  tubercles.  Certain 
of  the  mesenteric  glands  were  also  cheesy,  but  to  a  less  extent  than  the 
bronchial.     The  disease  of  the  brnu.<-ii:al  glands  was  evidently  primary, 


LUXGS.  163 

the  tubercles  of  the  lungs  and  abdominal  organs  being  apparently  quite 
recent.  The  accompanying  woodcut,  from  a  photograph  by  Mr.  Mason, 
the  photographer  at  Bellevue  Hospital,  represents  a  posterior  view  of 
the  lungs  and  air-passages. 

In  no  case  have  I  found  tubercles  in  the  heart  or  pericardium,  though 
they  have  been  observed  in  rare  instances  in  the  latter.  The  mesenteric 
glands  were  enlarged  by  hyperplasia,  and  more  or  less  cheesy,  in  30 
cases,  Avere  apparently  normal  in  2  cases,  while  in  the  remaining  4 
cases  their  condition  was  not  stated.  In  most  of  the  patients  the  mesen- 
teric glands  were  smaller  and  less  cheesy  than  the  bronchial,  but  in  a 
fcAV  instances  they  were  larger  than  the  bronchial  and  more  cheesy. 

It  is  a  noteworthy  fact,  as  bearing  on  the  causative  relation  of  these 
glands  to  tubercles,  that  not  infrequently  the  amount  of  hyperplasia 
and  cheesy  degeneration  occurring  in  the  former  was  very  considerable, 
while  the  tubercles  in  the  lungs  or  else^vhere  were  small,  even  minute, 
semi-transparent,  and  evidently  of  recent  formation.  It  appeared  as 
if  in  such  cases  the  glandular  hyperplasia  and  degeneration,  bronchial 
or  mesenteric,  or  both,  preceded  the  general  tubercular  disease,  and 
probably  sustained  an  etiological  relation  to  it.  Since  the  cases  which 
furnished  the  above  statistics  occurred,  my  clinical  experience  with 
tuberculosis  has  greatly  increased,  but  nothing  new  or  different  has 
been  observed  at  autopsies. 

Abdominal  Viscera. — In  children,  tubercles  in  the  solid  organs  of 
the  abdomen  rarely  give  rise  to  appreciable  symptoms,  since  they  are 
small  and  di.^seminatcd,  not  impairing  materially  the  function  of  the 
part  in  which  they  are  located.  On  the  other  hand,  peritoneal  and 
intestinal  tubercles,  and  the  enlarged  and  cheesy  mesenteric  glands, 
give  rise  to  symptoms  which  recjuire  description.  The  most  frequent 
seat  of  peritoneal  tubercles  is  upon  the  attached  surface  of  the  peri- 
toneum, where  they  are  formed  in  the  connective  tissue.  They  are 
distinctly  seen  through  the  peritoneum,  and  cause  some  prominence  of 
it.  Exceptionally  their  seat  is  upon  its  free  surface.  Every  ])ortion  of 
the  peritoneum,  whether  visceral,  ])arietal,  or  omental,  is  lialde  to  tuber- 
cles, but  generally  tuberculization  of  so  extensive  a  surface  does  not 
occur  in  any  one  case.  The  tubercles  are  spherical  or  lenticular,  and 
most  of  them  small.  Sometimes  they  are  very  numerous,  but  so  minute 
as  to  be  scarcely  visible.  They  are  gray  or  yellow,  according  to  the 
age.  Peritoneal  tubercles  often  produce  circumscribed  peritonitis, 
causing  adhesion  of  opposite  surfaces.  The  tubercles  in  themselves 
ttinnot  be  detected  by  palpation  ;  but  masses  or  placques  com])Osed  of 
tubercles  and  inflammatory  products  arc  sometimes  so  large  that  they 
can  be  felt  through  the  abdominal  walls. 

The  symptoms  of  peritoneal  tuberculosis  are  attributable,  for  the  most 
part,  to  the  peritonitis.  Among  them  may  be  enumerated  abdominal 
tenderness  or  pain,  meteorism,  ascites — usually  slight — and  derange- 
ment of  the  bowels,  commonly  di;irrh(ea.  As  tul)ercles  in  this  situa- 
tion occur,  in  most  cases,  subse([uently  to  tubercles  elsewhere,  the 
symptoms  which  have  been  described  are  associated  with  and  are  sub- 
ordinate to  others. 

Stomach  and  Intestines. —  The  most  common  seat  of  gastro-intestinal 


164  TUBERCULOSIS. 

tubercles  is  the  small  intestine,  and  more  frequently  its  lower  portion, 
near  the  ileo-Ccecal  valve,  than  its  upper  or  central.  They  are  rare  in 
the  tluodenum  or  contiguous  part  of  the  JLjunum.  They  are  developed 
ordinarily  in  the  connective  tissue,  either  that  lying  under  the  mucous 
or  the  serous  surface. 

Gastro-intestinal  tubercles  are  often  accompanied  by  ulceration  of  the 
adjacent  mucous  membrane.  But  in  a  certain  proportion  of  cases  there 
is  probably  no  causative  relation  of  the  tul)ercles  to  the  idcers,  for 
ulceration  of  this  membrane  is  not  infrequent  in  the  tuberculosis  of 
children,  when  there  are  no  tubercles  in  the  Avails  of  the  stomach  or 
intestines.  The  following  statistics  of  Rilliet  and  Barthez,  relating  to 
this  point,  will  aid  to  an  understanding  of  the  symptoms. 

~  v      1      •  n      r    .  1     -  f  with  ulcers,  6  cases. 

Tubercles  in  walls  of  stomach,   t  cases,  <      -.i      *     i  i 

'  '  \  without  ulcers,  1  ca?e. 

Ulcers  of  gastric  mucous  membrane,  without  gastric  tubercles,  14  cases. 

m  1.      1      ■  11  •    .     ■•  on  f  with  ulcers,  70  cases. 

lubercles  in  small  intestine.',  oi  cases,  <      -.1.1  io 

'  '  [  without  ulcers,  12  cases. 

Ulcers  without  tubercles  in  small  intestines,  51  cases. 

rri  1        1       •     1  •    i    i-         1-  f  with  ulcers,  10  eases. 

Tubercles  in  large   intestine,  lo   cases,-;      .,,       .      ,'  r        « 

=■  '  '  (^wiihdut  ulcers,  5  cases. 

Ulcers  in  large  intestine,  without  tubercles,  47  cases. 

The  ulcers  have  vascular,  thickened,  and  infiltrated  borders.  Their 
diameters  vary  from  a  line  to  half  an  inch  or  more,  and  their  general 
form  is  circular,  or,  if  two  or  more  unite,  irregular.  Tubercular  ulcers 
of  the  stomach  are  mostly  in  the  great  curvature,  those  in  the  small  intes- 
tines in  the  ileum  and  lower  part  of  the  jejunum,  and  those  of  the  large 
intestine  in  the  ctecum. 

The  following  table  exhibits  the  state  of  the  principal  abdominal 
viscera  in  the  3(3  cases  embraced  in  my  statistics : 

LiTer.  Spleen.  Kiiiueys. 

Tubercular  . 12 

Non-tubercular 16 

Not  stated 8 

Fatty 5 

In  no  instance  did  I  observe  tubercular  softening  in  the  abdominal 
organs,  and  a  large  proportion  of  the  tubercles  in  the  liver,  spleen,  and 
kidneys  were  still  in  the  first  stage.  In  the  five  cases  in  which  the 
liver  was  recorded  fitty,  this  state  of  the  organ  was  obvious  to  the  sight, 
as  it  is  in  tuberculosis  of  the  adult.  A  moderate  excess  of  fat  in  the 
hepatic  cells  may  have  been  present  in  some  of  the  other  cases,  but  it 
was  not  sufficient  to  be  appreciable  without  the  microscope.  It  is  to  be 
remarked  that  in  the  five  cases  in  which  the  liver  was  recorded  fatty, 
this  organ  contained  no  tubercles.  The  spleen  is  seen  to  have  been  the 
most  frequent  setit  of  tubercles  of  all  the  viscera,  except  the  lungs.  In 
fourteen  cases  the  intestines  were  examined ;  and  in  five,  tubercles  dis- 
covered developed  in  their  connective  tissue.  The  intestinal  tubercles 
were  small,  and  ulceration  had  occurred  of  the  mucous  membrane  which 
covered  them. 

The  brain  wtis  examined  in  fifteen  ctises.     In  twelve  the  amount  of 


22 
6 

1 
21 

8 

14 

0 

0 

ABDOMIXAL    VISCERA.  165 

cerebro-spinal  fluid  varied  from  gss  to  §v  bv  estimation.  In  two 
others  the  records  state  that  there  was  a  considerable  amount  of  .this 
fluid,  the  exact  quantity  not  being  given,  while  in  the  remaining  ease 
congestion  of  the  brain  and  meninges  was  noticed,  but  nothing  was 
recorded  in  regard  to  the  amount  of  cerebro-spinal  fluid.  The  increase 
of  the  cerebro-spinal  fluid  in  tuberculosis  is  attributable  to  wasting  of 
the  brain,  a  liydroceplialus  ex  vacuo,  and  in  some  cases  to  passive  con- 
gestion and  serous  transudation,  due' to  feeble  circulation,  or  obstructed 
flow  from  the  pressure  of  bronchial  glands  on  the  vessels  within  the 
thorax,  as  already  stated. 

Tubercles  were  present  in  the  pia  mater  in  three  cases  :  in  two  with 
fibrinous  exudation  ;  in  the  other  without  fibrin  or  other  evidence  of  in- 
flammation. Tubercular  meningitis  is  described  in  another  jnirt  of  this 
book. 

Symptoms. — The  symptoms  in  tuberculosis  of  children  arise  in  part 
from  the  diathesis,  and  in  part  from  the  tubercles.  Before  the  period 
of  tubercles,  there  are  signs  of  failing  health,  such  as  loss  of  appetite, 
flabbiness  of  the  soft  parts,  or  emaciation,  lassitude,  and  loss  of 
strength.  These  symptoms  continue  after  the  formation  of  tubercles, 
and  increase. 

The  features  are  ordinarily  pallid,  but  during  the  paroxysms  of  fever, 
to  which  tubercular  patients  are  subject,  they  may  be  flushed.  Lividity 
of  the  features,  due  to  imperfect  decarbonization  of  the  blood,  occurs, 
if  there  be  enlarged  bronchial  glands  which  compress  tlie  vessels  within 
the  thorax,  or  if  there  be  extensive  pulmonary  tuberculization,  or  pul- 
monary tuberculization,  whether  extensive  or  not,  which  is  complicated 
by  capillary  bronchitis  or  pneumonia. 

The  skin  is  nearly  natural,  or  it  loses  its  flexibility  and  softness,  and 
becomes  dry  and  rough.  In  some  patients  there  is,  at  times,  general 
or  partial  furfuraceous  desipiamation  of  the  skin,  due  to  exaggerated 
development  of  the  epidermis.  Children,  like  adults,  notwithstanding 
the  general  dryness  of  the  surface,  are  liable  to  perspirations  at  night 
and  in  sleep.  This  symptom  is  less  frequent  at  the  commencement 
than  at  an  advanced  period,  and  in  acute  than  in  chronic  cases,  in 
young,  namely,  those  under  throe  or  four  montlis,  than  in  older  children. 
It  is  more  abundant  about  the  head  and  limbs  than  elsewhere,  and  is 
sometimes  confined  to  these  parts. 

Anasarca  is  not  infrecjuent.  It  sometimes  arises  from  obstructed 
circulation,  in  consequence  of  compression  of  the  thoracic  vessels  by 
enlarged  lymphatic  glaiuls;  in  other  cases  it  is  due  to  diminislie(l  plas- 
ticity of  the  bhjod,  a  result  of  the  tubercular  cachexia.  The  latter  is 
the  more  common  cause.  It  is  not  an  important  syni|)tom,  on  account 
of  the  small  amount  of  serous  transudation,  and  the  character  of  the 
parts  in  which  it  occurs. 

I]maciation,  already  alluded  to,  is  early,  constant,  and  progressive. 
Under  the  age  of  six  or  eight  months  it  is  less  marked  than  in  older 
children,  many  preserving  considcrahle  rotundity  of  features  ami  form 
even  in  advanced  tuberculosis.  The  failure  of  tlie  strengtii  corresjionds 
in  amount  and  progress  with  the  emaciation.  Sligiit  at  first,  and  ex- 
hibited  only  by  a  degree  of  lassitude,  it  gradually  increases,  till  for 


166  TUBERCULOSIS. 

■weeks  before  death  the  little  patient  is  fatigued  by  the  ordinary  mus- 
cular movements,  and  is  disposed  to  keep  quiet. 

The  nervous  system  is  not  ordinarily  affected  except  in  cases  of  intra- 
cranial tubercles.  In  acute  tuberculosis,  or  tuberculosis  complicated 
by  severe  inflammation,  there  may  be  agitation  and  delirium,  especially 
at  night. 

In  most  patients  the  mucous  membrane  of  the  buccal  cavity  presents 
its  normal  appearance,  Avith  the  exception  of  a  moist  fur  upon  the 
tongue,  and  a  paler  hue  than  normal  of  its  surface  generally.  In  acute 
tuberculosis,  and  in  cases  complicated  by  inflammation,  the  tongue  is 
sometimes  dry  and  bi'own.  The  appetite  may  be  normal  till  the  close 
of  life,  or  it  is  poor  or  changeable.  Occasionally  it  is  increased, 
although  the  disease  is  progressing.  The  bowels  are  regular  or  relaxed. 
Diarrhoea  may  be  a  prominent  symptom,  even  Avhen  there  are  no  intes- 
tinal tubercles  or  ulceration.  Meteorism  and  fulness  of  the  abdomen 
are  common. 

Fever,  constant,  but  usually  with  evening  exacerbation,  is  rarely 
absent.  It  continues  for  -weeks  or  months.  During  the  exacerbation 
the  pulse  rises  to  120,  140,  or  even  to  180  beats  per  minute,  and  there 
is  a  corresponding  exaltation  of  the  temperature,  Avhich  in  the  latter 
part  of  the  day,  without  inflammatory  complication,  ranges  from  100° 
to  102°  or  103°.  The  febrile  movement  is  a  symptom  of  diagnostic 
value  as  regards  the  nature  of  the  disease,  though  it  does  not  indicate 
the  seat  of  the  tubercles. 

In  addition  to  the  symptoms  now  described,  there  are  special  symp- 
toms, due  to  tuberculization  of  the  different  organs.  In  young  children, 
on  account  of  the  fact  already  referred  to,  to  wit,  the  tendency  to  a 
generalization  of  tubercles,  there  is  apt  to  be  a  blending  of  the  symptoms 
which  arise  from  different  organs,  but  with  care  it  is  not  difficult  in  most 
instances  to  isolate  and  refer  them  to  their  proper  source.  The  following 
are  the  symptoms  Avhich  arise  from  tuberculization  of  the  more  im- 
portant organs. 

Encepiialon. — Thesymptoms  produced  by  tubercles  of  the  encephalon 
vary  according  to  their  seat  and  size,  and  the  structural  changes  in  sur- 
rounding parts  to  Avhich  they  give  rise.  Meningeal  tubercles,  which 
are  located  for  the  most  part  in  the  meshes  of  the  pia  mater,  and 
ordinarily  along  the  course  of  the  small  arteries,  are,  as  a  rule,  small, 
not  more  than  a  line  in  diameter,  and  they  may  remain  latent  for  a 
considerable  time.  In  the  majority  of  cases,  however,  they  sooner  or 
later  cause  meningitis,  the  symptoms  of  Avhich  arcAvell  known  and  need 
not  be  described.  But  tubercles  in  this  situation  do  sometimes  give 
rise  to  symptoms  when  there  is  no  meningeal  inflammation.  They 
occasion  congestion  of  the  surrounding  vessels,  and  serous  transudation, 
and,  if  developed  on  the  under  surface  of  the  pia  mater,  they  may  pro- 
duce symptoms  by  encroaching  upon  and  irritating  the  brain;  for  they 
are  sometimes  so  much  embedded  in  the  convolutions  that  careful  exam- 
ination is  required  in  order  to  determine  that  they  are  meningeal,  and 
not  cerebral.  Among  these  symptoms  may  be  mentioned  headache, 
frontal  or  occipital,  sometimes  intermittent,  nausea,  melancholy,  and  in 
certain  cases  the  symptoms  produced  by  serous  transudation. 


EXCEPHALOX.  167 

The  symptoms  of  cerebral  are  in  part  similar  to  those  of  meninoreal 
tubercles,  but  in  most  cases  others  of  a  neuropathic  character'  are 
present,  which  serve  for  differential  diagnosis.  The  differences  as 
regards  the  symptoms  of  different  patients  affected  Avith  cerebral  tubar- 
cles  are  attributable  in  part  to  the  fact  that  their  size  and  rapidity  of 
growth  vary,  but  more  to  the  difference  in  their  seat ;  for  any  part  of 
the  brain  may  be  the  seat  of  tubercles,  though  certain  portions,  as  the 
cerebellum,  are  more  frequently  affected  than  others. 

The  child  with  cerebral  tubercles  is  quiet,  but  irritable  and  easily 
excited.  Delirium  is  not  common,  but  many  before  the  close  of  life 
exhibit  a  degree  of  mental  dulness.  The  headache,  common  in  cases 
of  cerebral  as  well  as  meningeal  tubercles,  may  be  nearly  general,  or  it 
is  frontal,  parietal,  or  occipital,  according  to  the  seat  of  the  tubercles. 
It  is  often  lancinating,  often  intermittent. 

Clonic  convulsions  occur  toward  the  close  of  life.  Exceptionally 
they  are  among  the  earliest  symptoms.  Observations  have  failed  to 
establish  any  relation  between  the  seat  of  t\Q  tubercles  and  the  locali- 
zation of  the  convulsions.  The  convulsions  may  be  unilateral,  while 
the  tubercles  are  in  both  hemispheres ;  or  general,  while  the  tubercles 
are  on  one  side  only. 

The  severity  and  duration  of  the  convulsive  attacks,  and  the  frequency 
of  their  occurrence  in  tuberculosis  of  the  brain,  vary  greatly  in  different 
patients.  They  have  been  attributed  to  softening  of  the  cerebral  sub- 
stance, which  sometimes  occurs  immediately  around  the  tubercles,  to 
local  congestions  excited  by  them,  and  also  to  serous  effusions  in  the 
ventricles.     The  convulsions,  sooner  or  later,  end  in  paralysis  or  coma. 

Contraction,  or  tonic  convulsion  of  certain  muscles,  is  sometimes 
observed.  Its  most  frequent  seat  is  in  the  muscles  of  the  back,  and  of 
one  or  both  of  the  lower  extremities.  It  is  a  late  symptom.  It  occurs 
in  those  cases  in  which  there  is  softening  around  the  tubercles,  and 
usually  in  the  muscles  of  the  opposite  side. 

Paralysis  is  also  a  late,  but  not  an  infrequent  symptom.  It  is  pre- 
ceded by  headache,  and  sometimes,  as  alrendy  stated,  by  convulsions. 
Occurring  as  a  symptom  of  tuberculosis  of  the  brain,  it  is  due  either  to 
pressure  on  a  cranial  nerve,  or  to  compressif)n  and  perhaps  softening  of 
the  cerebral  substance.  The  paralysis  may  l)e  paraplegic,  commencing 
as  feebleness  of  the  lower  extremities,  and  increasing  until  it  becomes 
complete,  or  a  more  or  less  complete,  hemiplegia.  In  ]);ira])logia  due 
to  tubercles  of  the  brain,  the  cerebellum  is,  as  a  rule,  their  .seat;  while 
paralysis  of  one  side,  or  of  certain  muscles  of  one  side,  indicates  tuber- 
cles of  the  opposite  cerebral  hemisphere  ;  but  there  are  exceptions. 
Paralysis  of  the  third  cranial  nerve  gives  rise  to  ptosis,  of  the  sixth  to 
paralysis  of  the  external  motor  nerves  of  the  eye,  and  therefore  to  in- 
ternal strabismus. 

Feebleness  or  loss  of  vision,  inequality,  oscillation,  and  fnially  dilata- 
tion of  the  pupils,  are  not  infre(juent  sympt-onis  of  tuberculosis  of  the 
brain,  and  they  possess  great  diagnostic  value.  Atrophy  of  the  optic 
nerve,  causing  amaurosis,  sometimes  results  from  tubercles  as  well  as 
other  tumors  of  the  brain.  Atrophy  of  this  nerve  occurs  not  only 
when  the  tubercles  are  so  located  as   to  press  on  the  optic  tract,  in 


i68  TUBERCULOSIS. 

which  case  the  explanation  is  apparent,  but  also,  in  certain  patients, 
when  the  tubercles  are  in  other  parts  of  the  brain.  In  these  last  cases 
it  is  thought  by  Brown-Sequanl  and  otiiers  that  the  imperfect  nutrition 
of  the  nerve  is  due  to  contractiun  of  its  nutrient  vessels,  produced  by 
the  tubercles  through  reflex  action. 

In  tuberculosis  of  the  brain,  symptoms  pertaining  to  the  respiratory, 
circulatory,  and  digestive  systems  are  either  absent  or  are  quite  sub- 
ordinate to  those  of  a  neuropathic  character.  Slowness  of  the  pulse, 
with  or  without  intermittencc,  has  sometimes  been  observed,  and  it  is 
therefore  a  symptom  of  some  diagnostic  value.  Toward  the  close  of 
life  both  pulse  and  respiration  are  apt  to  be  accelerated.  Vomiting, 
constipation,  and  retraction  of  the  abdomen,  which  are  so  common  in 
meningitis,  are  only  occasional  symptoms. 

Bronchial  Glaxds. — During  the  progress  of  tuberculosis,  hyper- 
plasia, cheesy  degeneration,  and  softening  of  various  lymphatic  glands 
may  occur  throughout  the  body,  but  the  bronchial  and  mesenteric 
are  not  only  those  which  are  most  frequently  affected,  but  they  are  the 
only  glands,  unless  in  exceptional  instances,  which  materially  increase 
the  danger  or  give  rise  to  special  symptoms.  These  symptoms  either 
have  a  mechanical  cause,  namely,  the  pressure  exerted  by  the  enlarged 
glands  on  contiguous  parts,  or  they  are  due  to  softening  of  the  glands 
and  consecutive  inflammation  and  ulceration. 

The  following  are  the  principal  symptoms  due  to  compression.  Some 
of  them  are  not  infre(|uent,  others  are  rare.  Compression  of  the  pul- 
monary veins  retards  the  flow  of  blood  from  the  lungs  to  the  left  auricle, 
giving  rise  to  congestion,  and,  in  extreme  cases,  oedema  of  the  lungs, 
Avith  sanguineous  extravasation  into  the  lung-substance,  congestion  of 
the  riglit  cavities  of  the  heart,  hepatic  veins,  and  of  the  systemic 
capillaries  generally.  Compression  of  the  pneumogastric  nerve,  or  of 
the  recurrent  laryngeal,  Avhich  is  the  motor  nerve  of  the  laryngeal 
muscles,  modifies  the  voice,  and  produces  a  cough  which  is  apt  to  be 
spasmoilic.  The  cough  resembles  that  of  pertussis,  and  has  been  mis- 
taken for  it,  but  it  is  not  so  violent  or  protracted.  The  voice,  clear 
and  natural  at  first,  becomes  by  degrees  hoarse  or  feel)lc  from  deficient 
innervation  of  the  laryngeal  muscles. 

An  enlarged  gland,  or  mass  of  glands,  lying  against  the  trachea  or 
one  of  the  bronchial  tubes  (this  may  occur  with  tubes  up  to  the  tliinl  or 
fourth  division),  and  pressing  its  walls  inward,  obviously  obstructs  more 
or  less  the  current  of  air.  If  there  be  considerable  obstruction,  a  loud, 
sonorous  rjlle  is  produced,  which  is  heard  distinctly  at  a  distance  from 
the  chest,  obscuring  other  rales.  It  is  loudest  when  the  patient  is 
agitated,  and  it  sometimes  intermits.  Feeble  respiratory  murmur, 
dyspnoea,  and  a  cough  are  not  infrequent  in  bronchial  phthisis.  Di- 
minished intensity  of  the  respiratory  murmur  is  general  or  partial, 
according  to  the  seat  of  the  compression.  It  has  been  most  frequently 
observed  at  the  summit  of  the  lungs.  In  certain  patients  this  symp- 
tom is  not  constant,  the  respiration  being  for  a  time  feeble  and  then 
normal.  The  dyspnoea  may  be  a  prominent  and  distressing  symptom, 
the  ahie  nasi  dilating,  and  the  inframammary  region  sinking  with  each 
inspiration.      The  cough  which  occurs  when   a  gland  presses  on  the 


LUNGS.  109 

trachea  or  bronchial  tube,  is  due  to  the  tracheitis  or  bronchitis  to  which 
the  pressure  gives  rise.  If  ulceration  occur  at  the  point  of  pressure, 
the  cough  continues  as  long  as  the  ulcer  remains.  Compression  of  the 
large  veins  within  the  thorax,  which  return  blood  from  the  head  and 
upper  extremities,  causes  more  or  less  congestion  of  these  parts,  with, 
perhaps,  transudation  of  serum  in  the  subcutaneous  connective  tissue, 
and  within  the  cranium.  Karely,  a  softened  gland  by  ulceration  gives 
I'ise  to  other  symptoms  than  those  mentioned,  namely,  hemorrhao-e  by 
ulceration  into  a  vessel,  or  pleuritis  or  pneumonitis  if  the  ulceration  be 
toward  the  lungs. 

Improvement  in  the  condition  of  the  patient  afiected  with  bronchial 
phthisis  is  not  unusual.  It  may  be  permanent,  but  in  most  patients  it 
is  temporary,  so  that  in  a  few  weeks  or  months  the  symptoms  are  as 
severe  as  before.  The  improvement  is  due  to  softening  and  elimination 
of  a  gland  which  had  given  rise  to  symptoms  by  its  mechanical  efiect, 
or  by  the  inflammation  which  it  had  excited. 

Physical  iSiux.s. — These  are  absent  or  obscure  in  the  incipient  dis- 
ease, when  the  glands  are  small,  and  they  are  most  marked  in  those 
cases  in  Avhich  the  glands  are  so  large  as  to  press  on  the  thoracic  walls, 
since  they  then  become  the  medium  for  the  transmission  of  sounds  to 
the  ear.  The  part  of  the  thorax  against  which  they  most  frecjuently 
press  is  the  dorsal  vertebrre,  from  the  first  to  the  sixth,  and  each  side 
of  the  vertebne,  and  less  frequently  the  upper  third  of  the  sternum. 
The  physical  signs  are  dulness  on  percussion  over  the  interscajiular 
space,  and  perhaps,  though  to  a  less  extent,  over  the  upper  part  of  the 
sternum,  and  bronchial  respiration  in  the  same  situations.  Occasionally 
a  bruit  can  be  detected,  due  to  the  uressure  of  a  gland  on  one  of  the 
large  vessels  of  the  chest. 

LuxGS. — A  cough  is  one  of  the  earliest  and  most  persistent  of  the 
symptoms  of  pulmonary  tuberculosis.  It  is  so  rarely  absent,  that  those 
of  large  experience  do  not  meet  with  more  than  one  or  two  such  cases. 
It  varies  in  severity  and  frequency.  If  the  tuberculosis  be  acute  and  its 
course  rapid,  the  cough,  even  from  its  commencement,  is  fiecpient,  so  as 
to  weary  the  patient  and  dejjrive  him  of  needed  rest.  But  in  ordinary 
cases,  that  is,  when  the  disease  is  clironic,  it  commences  gradually,  at- 
tracting little  attention  by  its  infVecpiency,  but  becoming  more  frequent 
and  painful  as  tlie  malady  advances. 

Ordinarily  the  cough  is  dry  in  the  first  weeks  or  luonths,  Imt  it 
becomes  looser  in  the  course  of  the  disease,  from  the  greater  amount  of 
bronchial  inilammation.  In  exceptiojial  instances  it  has  a  sp:isnindic 
character,  like  that  jtroduced  by  ])ressure  of  an  enlarged  bromhial  gland 
on  the  ]>neumogastric  or  recurrent  laryngeal  nerve.  This  occurs  from 
the  accumulation  of  viscid  mucus  in  one  or  more  of  the  bronchial  tubes, 
usually  in  dilated  portions  of  them,  from  which  it  is  with  diflicultv  ex- 
pectorated. 

The  resjjiration  in  })uhiionary  tuberculosis  is  accelerated  in  )iro|»ortion 
to  the  degree  of  tul)ei"culization.  Tuberculization  of  a  considerable  part 
of  both  liuigs  gives  rise  to  dyspnoea,  especially  when,  as  is  ordiiiai'ily  the 
CJise,  bronchial,  ))ulnionary,  or  jileuritic  inflanmiation  has  supervened. 
Pneumonitis  or  pleuritis  gives  rise  to  the  expiratory  nioan,  and  as  these 


170  TUBERCULOSIS. 

inflammations,  Avhen  induced  by  tubercles,  are  protracted,  this  symptom 
may  continue  for  weeks  or  months. 

Patients  under  the  age  of  six  years  do  not  expectorate,  or  but  rarely. 
After  this  age  expectoration  is  not  common  in  the  commencement  of 
pulmonary  tuberculosis,  but  in  the  confirmed  disease  it  is  a  pretty  con- 
stant attendant  of  the  cough.  Ilnemoptysis  is  also  rare  under  the  age 
of  six  years,  and  less  frequent  subsequently  than  in  the  adult.  It  is 
most  apt  to  occur  in  those  cases  in  Avhich  there  is  already  passive  con- 
gestion of  the  lungs,  produced  by  the  pressure  of  enlarged  bronchial 
glands  in  the  numner  already  described.  Patients  old  enough  to  make 
known  their  subjective  symptoms,  sometimes  complain  of  fugitive  pains 
under  the  sternum  or  between  the  shoulders. 

In  young  children  the  physical  signs  of  incipient  pulmonary  tubercu- 
losis are  wanting,  or  are  so  obscure  as  not  to  be  readily  recognized. 
This  is  due  to  the  small  size  and  dissemination  of  the  tubercles.  In 
older  children  the  physical  signs  appear  early,  and  are  readily  recog- 
nized, because,  as  a  rule,  the  tubercles  are  aggregated,  and  are  more 
frequently  at  the  apices  of  the  lungs  as  in  the  adult,  than  elsewhere. 
In  the  advanced  disease,  whether  in  infancy  or  childhood,  when  inflam- 
mation and  more  or  less  destruction  of  the  lung  substance  have  occurred, 
the  physical  signs,  so  far  from  being  obscure,  enable  us  in  most  cases, 
in  connection  with  the  history,  to  make  an-  immediate  and  positive 
diagnosis. 

In  young  children  affected  with  pulmonary  tuberculosis  the  irregular 
and  imperfect  expansion  of  the  lungs  produces  by  degrees  changes  in 
the  shape  of  the  thorax,  which  are  apparent  on  inspection.  In  some, 
the  lungs  being  habitually  imperfectly  inflated,  the  obliquity  of  the  ribs 
is  increased,  and  the  thorax  consequently  elongated,  while  its  antero- 
posterior and  transverse  diameters  are  diminished.  This  obviously  in- 
creases the  convexity  or  arch  of  the  diaphragm,  so  that  this  muscle 
sometimes  lies  against  the  thoracic  walls  as  high  as  the  ninth  or  even 
eighth  rib.  If  the  costal  cartilages  are  yielding,  there  are  anterior  flat- 
tening of  the  chest  and  depression  of  the  sternum ;  if  they  are  Arm,  on 
account  of  the  more  advanced  age,  the  chest  remains  circular. 

Another  shape  of  the  thorax  is  not  infrequent  in  feeble  tubercular 
children,  especially  infants,  who  have  suftered  from  repeated  attacks  of 
bronchitis.  It  occurs  also  in  the  non-tubercular,  if  the  conditions  which 
favor  it  are  present.  The  conditions  are,  on  the  one  hand,  feebleness 
of  the  patient,  Avith  diminished  force  of  respiration  and  impaired  resi- 
liency of  the  ribs ;  and,  on  the  other,  obstruction  by  mucus  of  one  or 
more  of  the  bronchial  tubes.  Occlusion,  more  or  less  complete,  of  a 
bronchial  tube,  and  consequent  obstruction  to  the  current  of  air,  pro- 
duces a  corresponding  degree  of  collapse  in  the  portion  of  lung  to  which 
the  tube  leads.  The  parts  which  collapse  are,  in  most  cases,  the  lower 
lobes,  and  the  thin  anterior  margins  of  the  upper  lobes.  This  causes 
lateral  depression  of  the  lower  ribs,  except  such  as  are  pressed  outward 
by  the  abdominal  viscera,  and  an  anterior  projection  of  the  lower  part 
of  the  sternum.  The  shape  of  the  thorax  in  these  cases  differs  from 
that  in  rachitis,  in  the  fact  that  the  lateral  depression  does  not  extend 
to  the  upper  ribs,  nor  does  the  upper  part  of  the  sternum  project. 


PLEURA.  171 

Certain  precautions  should  be  observed  in  examining  the  chest  by 
percussion  and  auscultation.  The  child  should  sit  or  recline,  with  the 
arms  and  shoulders  in  the  same  position,  and  the  axis  of  the  trunk 
straight.  Inclination  of  the  trunk  to  either  side,  raising  or  depressing 
a  shoulder,  may  produce  an  appreciable  difference  in  the  two  sides  as 
regards  the  physical  signs.  Percussion  of  the  two  sides  should  be  prac- 
tised at  the  same  stage  of  respiration.  A  slight  difference  in  the  degree 
of  resonance  docs  not  afford  proof  of  disease,  unless  it  bo  observed  at 
different  examinations;  for,  in  feeble  children,  it  often  happens  that  all 
portions  of  the  lungs  do  not  expand  alike,  so  that  where  we  have  noticed 
slight  dulness  at  one  visit,  it  may  by  the  next  have  disappeared,  or  even 
at  the  same  visit,  if  forcible  inspirations  be  excited. 

The  physical  signs  ascertained  by  palpation,  auscultation,  and  per- 
cussion are,  as  in  the  adult,  vocal  fremitus,  bronchial  respiration, 
bronchophony,  and  dulness  on  percussion.  In  these  cases  in  whicli  the 
tubercles  arc  mainly  at  the  apices  of  tho  lungs,  diminished  expansion 
of  the  infraclavicular  region  is  observed  during  inspiration,  and  this 
part  of  the  thoracic  wall  is  permanently  depressed,  so  that  the  clavicles 
are  unusually  prominent.  If  there  bo  emphysema,  this  flattening  does 
not  occur,  or  is  slight.  Dulness  on  percussion,  though  more  frequently 
observed  in  the  infraclavicular  region  than  elsewhere,  may  bo  present 
in  different  isolated  places.  If  pneumonia  supervene,  the  dulness  not 
infrequently  extends  over  a  considerable  part  of  one  lung.  The  cracked- 
pot  sound  is  often  observed  on  percussion,  but  it  possesses  no  diagnostic 
value.  It  can  be  produced,  when  there  is  no  pulmonary  disease,  by 
percussion  over  a  bronchus. 

Bronchial  respiration  and  bronchophony  are  important  signs,  as 
indicating  solidification  of  the  lung,  but  they  do  not  shoAV  whether  the 
solidification  be  tuberbular  or  pneumonic,  or  the  two  conjoined.  This 
must  be  determined  by  the  history  of  the  case,  the  extent  of  surface 
over  which  these  signs  are  heard,  and  their  persistence.  AVhen  the 
tubercles  begin  to  soften,  and  the  lung-tissue  breaks  up,  moist  rales 
appear,  often  hoarse  and  gurgling,  obscuring  the  bronchial  respiration. 
A  cavity  in  the  lung,  or  pneumothorax,  is  attended  by  the  same  physical 
signs  as  in  the  adult. 

Plkura. — Little  need  be  said  in  reference  to  the  symptoms  tind 
pliysical  signs  of  tuberculosis  of  tlie  pleura,  since  this  affection  is  in 
most  instances  associated  with  tubt'rculosis  of  the  lungs,  and  is  not 
distinguishable  fr<>m  it.  But  now  and  then  the  jdeural  tubercles  are 
numerous  and  large,  giving  rise  to  symj)tonis,  Avhile  those  of  the  lungs 
are  small,  few,  and  without  symptoms,  or  attended  by  symptoms  which 
are  quite  subordinate.  Either  the  costal  or  visceral  portion  of  the 
pleural  may  be  the  seat  of  tubercles.  They  are  developed  directly  uiuler 
the  pleura,  or  upon  its  free  surface.  They  are  very  apt  to  occur  m  the 
newly  formed  connective  tissue  which  results  from  ])leuritis.  Those 
located  upon  the  free  surface,  or  under  the  costal  ])leura,  rarely  soften, 
while  those  under  the  visceral  pleura  sometimes  soften  and  cause  ulcer- 
ation. Occasionally  numerous  aggregated  tubercles  fo.*m  a  firm  con- 
tinuous layer  U[)on  the  surface  of  the  ])leura,  ])reventing,  if  upon  the 
visceral  pleura,  full  expansion  of  the  lung.      This  may  give  rise  to  a 


172  TUBERCULOSIS. 

degree  of  dulness  on  percussion,  and  feebleness  of  the  respiratory  mur- 
mur. Ordinarily,  however,  in  this  form  of  tuberculosis,  the  symptoms 
and  physical  sipns,  so  far  as  any  are  observed,  are  due  to  the  pleuritic 
inflammation  "which  the  tubercles  excite. 

Stomach  axd  Intestines. — The  symptoms  in  tuberculosis  of  the 
stomach  and  intestines  vary  according  to  the  seat  and  stage  of  the 
tubercles. 

Tubercles,  whether  gastric  or  intestinal,  are  not  at  first  accompanied 
by  symptoms,  or  the  symptoms  are  obscure  and  ill- defined.  Symptoms 
arise  when  inflammation  occurs  in  the  adjacent  tissues.  Diarrhoea  is 
one  of  the  most  common  and  persistent  of  the  symptoms.  The  alvine 
discharges  are  brown  and  thin,  and  sometimes,  in  advanced  cases,  very 
offensive.  They  may  be  streaked  with  blood  which  has  escaped  from 
the  ulcers.  Intestinal  tubercles,  developed  immediately  underneath 
the  peritoneal  coat,  sometimes  cause  local  peritonitis,  usually  of  little 
extent.  This  gives  rise  to  circumscribed  pain,  tenderness,  and  more  or 
less  meteorism. 

Diagnosis. — It  is  evident  from  the  foregoing  description  of  symptoms 
that  the  diagnosis  of  incipient  tuberculosis  is  much  more  difficult  in 
children  than  adults.  Before  commencing  the  examination,  it  is  best 
to  learn  the  hereditary  tendencies  of  the  fiimily  and  the  history  of  the 
patient,  especially  as  regards  antecedent  diseases  or  debilitating  agen- 
cies, and  the  duration  of  the  symptoms. 

Early  and  accurate  diagnosis  of  tuberculosis  in  the  child,  as  well  as 
in  the  adult,  is  now  rendered  possible  by  the  discovery  of  the  tubercle 
bacillus,  in  1882,  by  Koch.  This  bacillus  abounding  in  the  sputum, 
as  well  as  in  the  affected  organs  of  phthisical  patients,  having  a  slender 
rod-like  form,  liavint;  a  length  varvinc;  from  one-fourth  to  the  entire 
diameter  of  the  red  blood-corpuscles,  and  susceptible  of  a  peculiar 
staining  by  the  aniline  colors,  which  differentiates  it  from  all  other 
bacilli,  is,  as  we  have  stated  above,  believed  to  be  uniformly  present  in 
tuberculosis,  and  absent  in  other  conditions. 

Children  witli  tuberculosis  of  the  lungs  expectorate  comparatively 
little,  but  sufficient  sputum  can  probably  be  obtained  in  most  instances 
for  the  purpose  of  diagnosis.  The  presence  of  the  bacillus  indicates 
clearly  the  tubercular  nature  of  the  disease. 

Tuberculosis  of  the  encephalon  is  diagnosticated  with  more  difficulty 
than  that  of  the  thoracic  or  abdominal  organs ;  but  certain  of  these  organs 
are  in  most  patients  tubercidar  at  the  same  time,  and  the  knowledge  of 
the  fact  that  they  are  tiffected  aids  in  the  diagnosis  of  the  disease  of  the 
brain  or  its  meninges.  Among  the  symptoms  of  intracranial  tuber- 
culosis which  possess  diagnostic  value  may  be  mentioned  cephalalgia 
and  more  or  less  fever,  Avith  exacerbations  in  the  commencement  of  the 
disease,  and,  at  a  more  iidvanced  period,  strabismus,  inequality  or 
irregular  action  of  the  pupils,  impaiiment  of  vision,  retraction  of  the 
head,  and  convulsive  movements  or  paralysis. 

In  certain  cases  careful  observation  and  discrimination  of  symptoms 
are  requisite,  in  order  to  determine  whether  they  arise  from  intracranial 
tubercles,  or  from  congestion  of  the  brain  caused  by  obstruction  in  the 
venous  circulation  by  the  jiressure  of  enlarged  bronchial  glands. 


DIAGNOSIS. 


173 


The  diagnosis  of  bronchial  phthisis,  when  the  glands  are  still  small, 
is  necessarily  uncertain,  on  account  of  the  absence  of  symptoms.  When 
they  have  increased  in  size  and  are  so  located  as  to  press  on  the  pneu- 
moo^astric  or  recurrent  laryngeal  nerve,  producing  the  spasmodic  cough 
alreadv  described,  the  differential  diagnosis  between  that  disease  and 
pertussis  may  be  made  by  attention  to  the  following  facts  :  Bronchial 
phthisis  occurs  singly,  and  is  non-contagious,  Avhile  pertussis  occurs  as 
an  epidemic,  and  with  evidences  of  contagion.  There  arc  no  successive 
stages,  to  wit,  those  of  catarrh,  paroxysmal  cough,  and  decline,  as  in 
that  disease,  and  the  cough,  though  paroxysmal,  is  short,  and  without 
whoop  or  vomiting. 

In  feeble  children,  with  inherited  tubercular  diathesis,  emaciation, 
sweats,  and  a  chronic  cough,  with  the  absence  of  pulmonary  symptoms, 
should  excite  suspicions  that  the  bronchial  glands  are  involved.  The 
evidence  is  almost  conclusive  if  the  cough  become  paroxysmal,  and 
there  be  a  loud,  persistent  tracheal  or  bronchial  rale. 

Fig.  21.  ' 


Docillus  tuberculosis.     (Stoniberg  ) 

In  certain  patients  affected  with  this  form  of  tuberculosis,  we  have 
seen  that  the  prominent  symptoms  are  due  to  compression  of  one  or 
more  of  the  large  vessels  in  the  chest.  Compression  of  these  vessels, 
and  consequent  retarded  circulation,  may  be  confidently  referred  to  en- 
larged bronchial  glands,  since  aneurism,  carcinomatous  or  other  tumors, 
which  would  produce  a  similar  result,  arc  very  rare  before  puberty. 
Sometimes  the  diagnosis  is  rendered  certain  by  the  ])hysical  signs 
observed  by  auscultation,  and  percussion  over  the  sternum  and  the 
interscapular  space.  The  condition  of  the  external  glands  should  also 
be  observed,  as  those  of  the  axilla,  neck,  and  groin. 


174  TUBERCULOSIS. 

The  diagnosis  of  pulmonary,  thougli  more  readily  made  tlian  that  of 
intracranial  and  bronchial  tuberculosis,  is  often  difficult  and  uncertain. 
This  is,  in  part,  explained  by  the  fact  that  the  tubercles  are  so  fre- 
quently disseminated,  while  emaciation  and  a  chronic  cough  are  not  in- 
frequent from  other  causes  than  tubercles.  Rachitis,  intestinal  worms, 
dentition,  simple  tracheal  or  bronchial  inflammation,  may  be  attended 
both  by  a  chronic  cough  and  emaciation.  Caution  is  therefore  requisite 
in  order  to  avoid  a  grave  error  in  diagnosis.  Precipitancy  in  the  diag- 
nosis of  doubtful  cases  is  worse  than  indecision,  and  it  is  often  best  to 
postpone  an  expression  of  opinion  as  to  the  nature  of  the  disease,  till 
the  case  has  been  observed  a  few  days. 

The  significance  and  importance  of  the  symptoms,  physical  signs,  and 
other  facts  on  which  a  diagnosis  must  be  based,  have  already  been  suffi- 
ciently pointed  out.  It  is  difficult,  in  foct  in  certain  cases  impossible, 
to  discriminate  by  the  physical  signs  between  simple  cheesy  pneumonia 
and  cheesy  pneumonia  which  has  ended  in  the  formation  of  tubercles. 
The  patient  has  an  attack  of  catarrhal  pneumonia  ;  but,  instead  of 
absorption  of  the  inflammatory  product,  cheesy  infiltration  occurs,  and 
the  lung  in  places  becomes  infiltrated  with  pus,  softens,  and  breaks  down. 
The  patient  presents  the  symptoms  and  physical  signs  of  phthisis.  He 
may  recover  after  a  protracted  sickness,  or  may  die.  The  disease  may 
renu\in  a  pneumonia ;  but  this  is  a  condition  of  the  lungs  which  favors 
the  development  of  tubercles,  and  in  a  certain  proportion  of  cases  tuber- 
cles do  form  in  the  last  weeks  of  life.  Though  the  differential  diagnosis 
in  such  cases  between  cheesy  pneumonia  and  tuberculosis  supervening 
on  pneumonia  is  impossible,  practically  the  discrimination  is  unimportant, 
as  the  same  treatment  is  reipiircd. 

Advanced  pulmonary  tuberculosis,  except  when  it  supervenes  upon 
pneumonia,  can  in  most  instances  be  readily  diagnosticated  by  a  careful 
examination.  Still,  it  is  to  be  recollected,  as  already  pointed  out,  that 
certain  of  the  symptoms  and  physical  signs,  which  occurring  in  the  adult 
would  afford  almost  positive  proof  of  pulmonary  tuberculosis,  not  infre- 
quently have  a  different  origin  in  children. 

The  diagnosis  of  tubercles  in  the  abdominal  organs  is  facilitated  by 
the  presence  of  symptoms  which  indicate  at  the  same  time  tuberculosis 
of  the  lungs.  Among  the  chief  diagnostic  signs  of  tuberculosis  of  the 
peritoneum  may  be  mentioned  meteorism  and  a  degree  of  tenderness  on 
pressure,  but  there  is  danger  of  mistaking  the  tympanitic  state  of  the 
intestines  common  in  ill-nourished  infants  and  the  rachitic,  or  the  ful- 
ness due  to  enlarged  s})leen  or  liver,  for  that  occasioned  by  peritoneal 
tuberculization,  and  vice  versa.  The  history  of  the  case,  and  a  careful 
examination  of  accompanying  symptoms,  and  the  shape  and  feel  of  the 
addomen,  usually  suffice  to  establish  the  diagnosis.  In  simple  gaseous 
distention  of  the  abdomen  there  is  an  absence  of  the  symptoms,  general 
and  local,  which  attend  tuberculosis :  rachitis  occurs  at  an  earlier  age 
than  peritoneal  tuberculosis,  and  digital  examination,  aided  by  percus- 
sion, enables  us  to  diagnosticate  enlargement  of  the  liv.er  or  spleen. 

Tubercular  enlargement  of  the  mesenteric  glands  cannot  be  positively 
diagnosticated  when  they  are  small.  When  they  have  attained  such  a 
size  that  they  can  be  felt  through  the  abdominal   walls,  palpation,  in 


TREATMENT.  175 

connection  with  the  history  and  symptoms  of  tuberculosis,  suffices  to 
establish  the  diagnosis.  The  glandular  tumors  can  be  diagnosticated 
from  other  tumors  by  the  fact  that  they  are  tender  on  pressure,  and 
occupy  the  umbilical  region,  \vhile  fecal  tumors  are  not  tender,  and  are 
located  in  the  iliac  or  lumbar  region.  Gastro-intestinal  tuberculosis 
cannot  be  positively  diagnosticated.  Protracted  diarrhoea,  or  frequent 
attacks  of  diarrhtea,  not  readily  controlled  by  medicine,  and  occurring 
in  tubercular  cases,  are  probably  associated  with  intestinal  ulceration  ; 
but  in  only  a  certain  proportion  of  cases  of  ulceration  are  there  also 
tubercles  in  the  walls  of  the  intestines,  as  we  have  seen  above. 

PRO(;xosrs. — Death  is  the  ordinary  result  of  tuberculosis  in  the 
child,  as  it  is  in  the  adult ;  but  now  and  then  one  recovers.  Hospital 
statistics  show  that  the  average  duration  of  the  disease  is  from  three  to 
seven  months.  Under  favorable  circumstances  it  is  more  protracted, 
even  to  two  or  three  years.  Those  succumb  soonest  who  inherit  a 
strongly  marked  tubercular  diathesis,  live  in  damp,  dark,  and  ill-venti- 
lated apartments,  and  whose  diet  is  scanty  or  of  poor  quality.  There- 
fore in  the  poor  quarters  of  the  city  tuberculosis  presents  a  worse  form 
and  pursues  a  more  rapid  course  than  among  families  in  better  circum- 
stances. 

Favorable  prognostic  signs  are  absence  of  tubercular  diathesis,  good 
appetite  and  general  health,  with  little  emaciation,  infrequency  of  cough, 
with  respiration,  pulse,  and  temperature  nearly  normal.  Such  symp- 
toms may  afford  hope  of  recovery  with  judicious  regimenal  and  thera- 
peutic measures.  On  the  other  hand,  if  the  symptoms  be  grave,  death 
is  inevitable,  unless  in  bronchial  phthisis,  in  which,  even  when  there  is 
considerable  urgency  of  symptoms,  the  offending  gland  is  sometimes 
eliminated  by  softening  and  ulceration,  and  the  patient  improves  tempo- 
rarily, if  he  do  not  ultimately  recover.  Complete  and  permanent 
recovery  is,  however,  quite  exceptional. 

Death  in  tuberculosis  of  children  may  occur  from  exhaustion  induced 
by  the  general  disease,  or  from  the  local  effects  of  the  tubercles.  Thus, 
in  intracranial  tuberculosis  it  may  result  from  meningitis  ending  in 
convulsions  and  coma ;  in  pulmonary  tuberculosis,  from  dyspnoea, 
thougli  more  frequently  from  exhaustion  ;  in  that  of  tlie  bronchial 
glands,  from  dyspnoea  or  hemorrhage;  in  that  of  the  abdominal  organs, 
from  peritonitis  or  protracted  diarrhoea. 

Treatment.  Proph/Iactic. — Since  caseous  substance  occurring  in 
some  part  of  the  system  is  a  common  cause  of  the  development  of 
tubercles,  it  is  evident  that  measures  which  tend  to  prevent  the  occur- 
rence of  this  substance  are  prophylactic  of  tuberculosis  :  and  since,  in 
children,  cheesy  matter,  in  most  instances,  is  a  })roduct  of  strumous  in- 
flammations, the  anti-strumous  remedies  arc  demanded  in  the  prophy- 
lactic as  well  as  curative  treatment  of  tuberculosis.  Therefore,  the 
strumous  child  should  be  watched  with  great  care,  and  such  measures  be 
employed  as  are  calculated  to  invigorate  his  system.  If  the  mother 
belong  to  a  decidedly  tubercular  family,  or  give  the  history  of  scrofula 
in  her  chihlhood,  it  is  better  that  she  do  not  suckle  her  infant,  but 
employ  a  healthy  Avet-nurse.  Children  who  are  weaned  should  have 
plain,  but  nutritious  and  easily  digested  diet,  a  i)art  of  which  should 


176  TUBERCULOSIS. 

be  milk.  Residence  in  an  airy  and  salubrious  locality,  outdoor  life,  a 
scrupulous  avoidance  of  exposure  by  "wbicli  cold  might  be  contracted, 
are  important,  in  order  to  the  continued  latency  of  the  diathesis. 

Loss  of  flesh  or  appetite,  or  other  evidences  of  failing  health,  indi- 
cate the  need  of  other  measures  of  a  therapeutic  character.  Alcoholic 
stimulants  should  now  be  allowed  three  or  four  times  daily  in  milk  ; 
cod-liver  oil,  with  half  its  quantity  of  syrup  of  the  lactophosphate  of 
lime,  to  which  the  syi'up  of  the  iodide  of  iron  is  added,  Avill  be  found 
useful  for  these  cases,  as  it  is  in  the  ordinary  forms  of  scrofula.  The 
various  bitter  preparations  containing  iron,  as  the  citrate  of  iron  and 
quinine,  elLx.  calisaya  bark  with  iron,  etc.,  should  be  employed,  when, 
for  any  reason,  cod-liver  oil  is  not  tolerated.  By  the  employment  of 
such  precautionary  measures  as  soon  as  indicated,  multitudes  of  children 
might  be  saved  from  tuberculosis  who  now  perish. 

Curative. — The  medicinal  agents  which  are  required  in  ordinary 
cases  have  been  already  mentioned,  namely,  cod-liver  oil,  iron,  some- 
times the  vegetable  tonics,  and  alcoholic  stimulants.  The  oil  may  be 
given  in  emulsion  to  disguise  the  unpleasant  flavor,  or,  Avhich  I  ])icfer, 
mixed  with  half  its  quantity  of  syrup  of  the  lactophosphate  of  lime,  as 
recommended  for  the  treatment  of  scrofula. 

If  the  cod-liver  oil  be  not  tolerated,  or  if  it  impair  the  appetite,  it 
should  be  discontinued.  In  cases  of  diarrhoea  it  is  of  little  or  no  benefit 
and  may  do  harm.  Under  such  circumstances  patients  sometimes  do 
better  with  simple  regimenal  measures,  aided  by  alcoholic  stimulants, 
and  one  of  the  least  unpleasant  of  the  tonics,  as  wine  of  iron  or  the 
calisaya  bark.  The  regimen  already  recommended  for  prevention  is 
also  required  as  ])art  of  the  curative  treatment. 

Certain  modifications  of  treatment  are  demanded  on  account  of  the 
localization  of  the  tubercles.  Intracranial  tuberculosis,  as  soon  as 
diagnosticated,  should  be  treated  by  pretty  decided  doses  of  iodide  of 
potassium,  though,  unfortunately,  there  is  little  prospect  of  improve- 
ment. The  glandular  disease,  whether  bronchial  or  mesenteric,  requires 
the  iodide  of  iron,  with  or  without  that  of  potassium.  Pneumonitis  or 
pleui'itis,  so  frequent  a  complication  of  pulmonaiy  tuberculosis,  requires 
emollient  poultices,  with  moderate  counrer-irritation,  and  the  judicious 
use  of  opiates  with  stimulants.  The  peritonitis  occurring  in  abdominal 
tuberculosis,  which  is  usually  circumscribed,  is  best  treated  by  fomenta- 
tions and  poultices,  with  opiates,  and  the  diarrhoea  by  subnitrate  of 
bismuth  and  chalk,  five  to  ten  grains  of  each,  or  the  bismuth  with 
Dover's  powder,  or  a  more  active  astringent. 


ETIOLOGY.  1T7 


CHAPTEK  lY. 

SYPHILIS, 

Syphilis  in  infancy  and  childhood  presents  itself  under  two  forms, 
namely,  the  congenital  and  acquired;  tiie  former  is  the  more  frequent. 

Etiology. — Congenital  syphilis  may  be  derived  from  either  father  or 
mother.  Either  parent,  having  previously  had  syphilis,  may  transmit  it 
to  the  offspring,  although  at  the  time  free  from  syphilitic  symptoms. 
The  mother,  healthy  at  the  time  of  conception,  but  infected  with  syphilis 
prior  to  the  eighth  month  of  gestation,  may  comm.unicatc  the  disease 
to  the  fcctus;  syphilis  contracted  in  the  eighth  or  ninth  month  does 
not  affect  the  foetus.  If  both  parents  have  syphilis,  the  infant  is  almost 
necessarily  syphilitic;  on  the  other  hand,  if  only  one  parent  be  affected, 
the  infant  may  or  may  not  be  contaminated.  Sometimes,  with  such 
parentage,  a  part  of  the  children  are  syphilitic,  and  a  part  healthy. 

Acquired  syphilis  in  infancy  and  childhood  may  be  received  through 
primary  lesions — that  is,  by  reception  of  the  virus  from  a  chancre  or 
bubo;  or  it  may  be  derived  from  certain  of  the  secondary  lesions.  In- 
oculation by  primary  lesions  may  occur  at  the  birth  of  the  infant,  from 
a  syphilitic  sore  in  the  vagina  or  upon  the  vulva  of  the  mother;  inocu- 
lation in  this  manner  is,  however,  rare.  Children  may  also  receive  the 
virus  from  primary  lesions  on  the  persons  of  nui'ses  or  companions. 
Infection  in  this  manner  is  sometimes  accidental,  and  sometimes  the 
result  of  criminal  conduct.  A  chancre  on  the  breast  of  the  wet-nurse 
not  very  infrequently  communicates  syphilis  to  the  nursling. 

The  contagiousness  of  "  secondary  manifestations,"  for  a  long  time 
doubted,  is  now  fully  established.  Syphilis  may  be  communicated  by 
the  secretion  or  exudation  of  a  mucous  patch,  or  a  secondary  sore. 
Hence  the  danger  of  lactation  by  unhealthy  wet-nurses,  though  they 
present  no  symptoms  of  recent  syphilis.  Excoriations  or  sores  upon 
the  nipple  or  breast  of  an  infected  wet-nurse  may  communicate  the 
disease  to  the  nursling;  and,  on  the  other  hand,  mucous  tubercles  or 
fissures  upon  the  lips  or  tongue  of  the  infected  infant  may  be  the  means 
of  contaminating  a  healthy  wet-nurse.  Many  such  cases  are  now  con- 
tained in  tlie  records  of  medicine.  Vaccination  by  means  of  the  scab 
is  also  a  mode  by  which  constitutional  syphilis  may  be  communicated. 
For  further  particulars  in  reference  to  this  subject  the  reader  is  referred 
to  our  remarks  on  vaccination. 

The  specific  ])riiKiph?  of  syjihilis  is  unknown.  Klebs  obtained  by 
cultivation  baciili  from  rods  and  spherules  which  he  found  in  indurated 
chancres.  With  the  cultivated  bacilli  he  produced  a  local  afl'ectinn  by 
inocidation  in  the  monkey,  which  resembled,  in  some  respects,  that  of 
syphilis,  and  in  other  respects  that  of  tuberculosis.  Ziegler  and  von 
llinecker  obtained  negative  results  from  similar  experiments.  (Zieglcr's 
Path.  Anatuniy.) 

V2 


178  SYPHILIS. 

Clinical  History. — The  effects  of  the  syphilitic  poison  upon  the 
development  of  the  foetus,  and  the  development  and  health  of  the  infant, 
are  different  in  different  cases.  The  foetus,  under  the  influence  of  the 
poison,  often  ceases  to  grow,  shrivels,  dies,  and  is  expelled,  long  before 
term ;  or  it  may  be  born  alive,  but  prematurely,  and  showing  clear  evi- 
dences of  the  disease,  as  soon  as  it  comes  into  the  world ;  or,  again,  it 
may  be  born  at  term,  but  dead.  So  frequently  is  sy])hilis  a  cause  of 
non- viability,  that,  as  Trousseau  has  remarked,  this  disease  should  be 
suspected  as  the  cause,  whenever  a  woman  repeatedly  aborts.  Abortion 
from  syphilis  commonly  occurs  at  or  about  the  sixth  month  of  gestation. 
In  those  cases  in  which  the  foetus  dies  from  sypliilis  there  is  often 
placental  syphilitic  disease,  namely,  an  undue  growth  of  cells  in  the 
villi,  which,  compressing  the  vessels,  gives  rise  to  fatty  degeneration, 
and  prevents  the  requisite  interchange  between  tlie  maternal  and  foetal 
blood.  (Harring,  Frankell.)  Frankell  designated  the  change  "  granu- 
lation-cell hypertrophy  of  the  placental  villi."  A^irchow,  in  one  case 
found  a  gummy  tumor  in  the  maternal  portion  of  the  placenta. 

When  a  fcetus  destroyed  by  syphilis  is  expelled,  it  is  apt  to  present  a 
macerated  appearance,  the  cuticle  being  detached  over  large  ])atches  of 
surface,  and  in  other  parts  raised  in  blebs,  with  a  thin,  puriform,  and 
offensive  fluid  underneath ;  the  liver  is  occasionally  indurated,  and  ab- 
scesses with  spots  of  inflammation  are  sometimes  observed  in  the  thymus 
gland;  the  anniiotic  fluid  is  offensive,  turbid,  and  of  a  greenish  or 
greenish-brown  appearance. 

If  the  foetus,  in  which  syphilitic  manifestations  have  begun  to  occur, 
have  reached  a  viable  age,  and  be  born  alive,  it  is  small  and  imperfectly 
developed,  often  shrivelled  and  senile  in  appearance.  The  skin  looks 
unhealthy,  and  it  may  exhibit  a  distinct  rash.  Bouchut  saw  a  seven 
and  a  half  months'  infant  born  alive,  with  an  eruption  of  a  copper  color 
upon  the  legs  and  arms,  and  onyxis  upon  the  fingers  and  toes.  The 
bullre  of  pemphigus  are  also  not  infrequent  upon  the  skin  at  birth,  or 
they  appear  within  a  few  days,  two  or  three,  after  birth.  The  smallest 
are  about  the  size  of  a  split  pea ;  but  many  are  considerably  larger ;  the 
largest  consist  of  two  or  more  which  have  coalesced.  They  contain  a 
thin,  greenish,  ])urulent  nuitter,  and  a])pear  most  frequently  upon  the 
palms  of  the  hands  and  soles  of  the  feet,  but  also  in  severe  cases  upon 
the  face  and  over  the  surface  of  the  body.  Recently  I  was  able  to 
diagnosticate  syphilis  in  an  infant  within  a  day  after  biilh,  by  its  small 
size  and  feebleness,  and  the  appearance  of  large  blebs  of  pemphigus 
upon  its  hands,  feet,  fingers,  and  toes,  over  which  the  skin  soon  broke, 
leaving  ti'oublesome  and  bleeding  sores;  coryza  commenced  about  the 
tAvelfth  day.  The  parents  seemed  healthy,  but  I  was  enabled  to  trace 
the  syphilitic  taint  to  the  mother.  Non-syphilitic  pemphigus,  the  result 
of  cachexia,  sometimes  appears  soon  after  birth,  but  its  primary  and 
usual  seat  is  around  the  neck  and  upon  the  body.  I  have  known  it  to 
appear  within  the  first  week  of  life,  and  end  fatally  by  the  close  of  the 
second  week.  I  have  not  found  it  difficult  to  distinguish  it  from  syphi- 
litic pemphigus  by  the  history  of  the  family,  and  its  absence  from  the 
palmar  and  plantar  surfaces  of  the  liands  and  feet.  Condylomata, 
mucous  patches,  and  stains  of  a  copper  color  are  the  principal  syphilitic 


CLIXICAL    HISTORY.  179 

affections,  besides  pemphigus,  which  have  been  observed  at  birth  on  the 
bodies  of  contaminated  infiints.  It  is  stated  that  M.  CuUerier,  in  ten 
years'  attendance  at  the  Hopital  de  Lorraine,  met  only  two  cases  of 
syphilitic  manifestations  at  birth,  and  Victor  de  Meric  only  two  cases  in 
forty-six  infants,  who  were  affected  with  congenital  syphilis  (Bumstead); 
but  in  the  practice  of  others  a  larger  proportion  have  exhibited  symp- 
toms at  birth.  Ordinarily  the  period  in  which  congenital  syphilis  is 
first  revealed  by  symptoms  is  between  the  fifteenth  and  fortieth  days. 
Rarely  the  manifestation  of  the  disease  is  delayed  several  months.  ]M. 
Diday  ascertained  the  time  of  the  commencement  of  symptoms  in  158 
cases  as  follows : 

Before  the  completion  of  one  month  after  birth,  in        .         .         .86 
Before  the  com[)letion  of  two  months  after  birth,  in      ,         .         .45 
Before  the  completion  of  three  months  after  birth,  in    .         .         .15 
At  four  months      ..........       7 

At  five  months        .         .         .         .         .    '     .         .         .         .         .1 

At  six  months         ..........       1 

At  eight  months     .....         .^       ....       1 

At  one  j'ear    ...........       1 

At  two  years  ...........       1 

In  cases  of  tardy  commencement  of  syphilitic  symptoms  it  is  probable 
that  the  poison  has  been  partially  eradicated  from  the  affected  parent  by 
appropriate  treatment. 

The  nutrition  of  the  infant  who  has  inherited  the  syphilitic  taint,  but 
does  not  exhibit  it  at  birth,  is  for  a  time  good,  but  it  begins  to  be  im- 
paired when  the  local  manifestations  of  syphilis  appear,  or  soon  after. 
The  system  gradually  wastes;  the  skin  loses  its  fresh  and  healthy  ap- 
pearance, and  becomes  sallow,  and,  after  a  time,  more  or  less  wrinkled ; 
tlie  features  become  pincbed  and  contracted,  and  wear  a  sad  expression. 
M.  Diday  says:  "Next  to  this  look  of  little  old  men,  so  common  in 
new-born  children  doomed  to  syphilis,  the  most  characteristic  sign  is  the 
color  of  the  skin."  Trousseau  thus  describes  this  discoloration  of  the 
surface:  "Before  the  healtli  becomes  affected,  the  child  has  already  a 
peculiar  appearance;  the  skin,  especially  thatof  tlie  face,  loses  its  trans- 
parency; it  becomes  dull,  even  when  there  is  neither  pufliness  nor 
emaciation;  its  rosy  color  disappears,  and  is  replaced  by  a  sooty  tint, 
which  resembles  that  of  Asiatics.  It  is  yellow,  or  like  coffee  mixed  with 
milk,  or  looks  as  if  it  had  been  exposed  to  smoke;  it  has  an  empyreu- 
matic  color,  similar  to  that  wbich  exists  on  the  fingers  of  persons  who  are 
in  the  habit  of  smoking  cigarettes.  It  appears  as  if  a  layer  of  coloring 
had  been  laid  on  uneqiiariy ;  it  sometimes  occupies  the  avIioIo  of  the  skin, 
but  is  more  marked  in  certain  favorite  spots,  as  the  forehead,  eyebrows, 
chin,  nose,  eyelids — in  short,  the  most  prominent  parts  of  the  face;  the 
deeper  parts,  such  as  tlie  internal  angle  of  the  orl)it,  tlie  liollow  of  the 
cheek,  and  that  wliich  separates  the  lower  lip  from  the  chin,  almost  always 
remain  free  from  it.  Although  the  face  is  commonly  the  part  most 
affected,  the  rest  of  the  body  always  participates  more  or  less  in  this  tint. 
The  infant  becomes  pale  and  wan." 

The  infant  whose  system  is  profoundly  affected  by  syphilis  rarely 
smiles,  and  its  voice  is  feeble  and  plaintive;  its  frequent,  whimpering crj 
is  quite  characteristic. 


180  SYPHILIS. 

CoRYZA  is  one  of  the  earliest  and  most  constant  of  the  local  affections 
in  infantile  syphilis.  It  is  slight  at  first,  attracting  little  attention  on 
the  part  of  the  parents,  Avho  are  not  aware  of  its  significance,  and 
usually  attribute  it  to  a  slight  cold;  but  it  gradually  increases.  It  gives 
rise  to  a  secretion  from  the  Schneiderian  membrane,  at  first  thin,  but 
which  becomes  more  consistent,  and  is  attended  by  the  formation  of 
scabs.  The  thickening  of  the  mucous  membrane,  in  consequence  of  the 
inflammation  and  the  presence  of  crusts,  narrows  the  passage  through 
the  nostrils  so  as  to  produce  snuffling  respiration,  and  sometimes  render 
nursing  difficult.  In  severe  cases  respiration  through  the  nostrils  is 
almost  wholly  prevented,  so  that  death  may  occur  from  inanition,  unless 
the  breast  be  milked  into  the  infant's  mouth,  or  it  be  fed  Avith  a  spoon  ; 
but,  ordinarily  even  in  grave  coryza,  it  continues  to  nurse,  though  obliged 
often  to  release  its  hold  of  the  nipple  to  obtain  breath.  It  is  when  coryza 
begins  to  interfere  with  lactation  that  it  first  alarms  the  parents.  The 
inflammation  at  the  same  time  may  affect  the  throat  and  larynx,  causing 
hoarseness  of  the  voice.  Ulceration  of  the  Schneiderian  membrane  and 
the  adjacent  cartilage  or  bone  is  rare  in  infancy  or  childhood,  although 
cases  occur  which  are  even  attended  with  more  or  less  flattening  of  the 
nose.  Diday  believes  that  the  discharge  which  accompanies  coryza  is 
in  great  part  due  to  mucous  patches  developed  on  the  Schneiderian 
membrane.  The  upper  lip,  over  Avhich  the  discharge  flows,  becomes 
red,  excoriated,  and  more  or  less  incrustcd.  The  coryza,  in  most  cases, 
coexists  with  other  local  syphilitic  affections.  Occasionally  it  occurs 
alone,  and  is  the  only  evidence  of  the  presence  of  the  specific  taint, 
except  such  as  is  aftbrded  by  the  malnutrition  and  general  appearance 
of  the  patient. 

Mucous  PATCHES  occur  in  most  patients.  They  are  developed  either 
upon  the  mucous  surfaces,  or  upon  parts  of  the  skin  which  are  thin  and 
exposed  to  friction,  aiul  such  as  are  moistened  by  secretion  or  transuda- 
tion fi-om  the  vessels  underneath.  The  most  common  seat  of  mucous 
patches  is  at  the  termination  of  mucous  canals ;  but  in  infancy,  on  account 
of  the  peculiar  delicacy  of  the  skin,  they  may  occur  upon  almost  any 
part  of  the  cutaneous  surface.  They  are  most  common,  however,  around 
the  anus,  upon  the  vulva,  scrotum,  umbilicus,  labial  commissures,  in  the 
axilliie,  and  behind  the  ears. 

Mucous  patches  upon  the  skin  present  a  rounded  border,  and  arc 
slightly  e]evated.  Their  color  has  been  compared  to  that  of  skin  which 
has  been  softened  by  the  prolonged  application  of  a  poultice.  Erosions 
and  cracks  sometimes  occur  in  the  patches,  from  which  a  thin  liquid 
exudes. 

Upon  mucous  surfaces  they  are  less  elevated  than  upon  the  skin,  and 
are  prone  to  ulcerate.  These  ulcerations,  commencing  at  the  centre, 
extend,  and  soon  the  mucous  patch  disappears,  and  its  site  is  occupied 
by  an  ulcer.  The  ulcer  may  be  circular,  oval,  elliptical,  crescentic  or 
irregular.  The  arches  of  the  fauces  are  a  common  seat  of  mucous 
patches. 

Roseola  is  an  occasional  symptom  of  infantile  syphilis.  "It  is  dis- 
tinguished," says  Diday,  ''by  patches  of  a  bright  rose-color,  circum- 
scribed, irregularly  rounded,  of  various  sizes  (most  frequently  about  as 


VISCERAL    LESIOXS.  181 

large  as  one  of  the  nails) ;  appearing,  by  preference,  on  the  belly,  lower 
])art  of  the  chest,  neck,  and  inner  surface  of  the  extremities."  The 
spots  do  not  readily  and  iully  disappear  by  pressure. 

rEiiPHiGUS  appearing  soon  after  birth  has  already  been  alluded  to. 
Its  most  frequent  seat,  Avhether  occurring  at  birth  or  as  a  subsequent 
manifestation,  is,  as  ■we  have  stated,  the  palms  of  the  hands,  soles  of  the 
feet,  the  fingers,  and  toes.  This  eruption  commences  b}'  a  violet  tint 
of  the  skin,  and  in  the  course  of  twenty-four  to  foi'ty-eight  hours  a 
Avatery  fluid  collects  underneath,  Avhich  soon  becomes  turbid.  The  skin 
peels  off,  and  sometimes  an  angry  sore  results,  which  bleeds  readily 
Avhen  rubbed  or  pressed.  In  other  and  more  favorable  cases  new  skin 
takes  the  place  of  that  which  is  lost.  Pemphigus  at  birth  is  a  precursor 
of  death,  but  Avhen  it  appears  for  the  first  time  some  weeks  alter  birth, 
it  is  a  less  unfavorable  prognostic  sign.  In  cases  of  recovery  it  disap- 
pears, with  proper  treatment,  in  two  or  three  weeks. 

Acne,  Impetigo,  and  Ecthyma  are  occasionally  observed  in  children 
afflicted  with  syphilis.  The  indurated  pustujcs  of  acne  occur  most  fre- 
quently upon  the  shoulders,  back,  chest,  and  buttocks.  The  pus  is 
sometimes  absorbed,  and  in  other  cases  discharged,  leaving  a  small 
cicatrix,  which,  after  a  time,  disappears.  Impetigo  ap])cars  most  fre- 
quently upon  the  face,  and  occasionally  upon  the  chest,  neck,  axilla,  and 
groin.  Unlike  simple  impetigo,  the  syphilitic  impetiginous  eruption  is 
surrounded  by  a  copper-colored  areola,  Ecth^-ma  occurs  upon  the  legs 
aud  buttocks  chiefly.  It  commences  as  violet-colored  spots,  which  are 
soon  transformed  into  pustules.  Ulcers  succeed,  which,  in  reduced  states 
of  the  system,  are  apt  to  enlarge  and  endanger  the  safet}'^  of  the  child. 
Of  the  three  pustular  eruptions,  acne,  according  to  Diday,  is  the  least 
serious — indicating  a  "less  confirmed  diathesis."  Ecthyma  is  the  most 
serious,  on  account  of  the  reduced  state  of  the  system  with  which  it  is 
usually  associated.  Syphilitic  papul.'c  and  squamro  are  rare  in  inflmts, 
but  cases  have  been  observed.  Onychia  occasionally  occurs,  though  less 
frequently  than  in  syphilis  of  the  adult. 

Yl-cekal  Lesioiss. — The  visceral  lesions  Avhich  result  from  the 
syphilis  of  inflincy  and  childhood  are,  suppuration  in  the  thymus  gland; 
gummy  tumors  in  certain  organs,  most  frequently  the  lungs  and  liver; 
increase  of  the  connective  tissue  of  the  liver,  known  as  svj)liilitic 
cirrhosis;  partial  ])erihepatitis,  with  depressions  resembling  cicatrices  on 
the  surface  of  the  liver;  peritonitis;  p.eriostitis,  with  thickening  of  the 
bone  and  exostosis. 

Suppurative  inflammation  in  the  thymus  gland  is  not  common,  or  hns 
not  been  fre([ueiitly  observed.  When  it  is  ])resent  the  gland  sometimes 
presents  its  normal  a]ipca ranee  externally,  and  tiie  abscess  is  only  discov- 
ered by  incisions.  (Jimimy  tumoi's  are  wliito  and  spheroidal;  some  are 
as  small  or  smaller  than  a  pin's  head,  while  others  are  as  large  as  a  pea, 
or  even  a  hazel-nut.  1  have  seen  a  considerable  number  of  tliem  not  as 
large  as  a  pin's  head,  in  the  liver  of  an  infant,  fiummy  tumors,  accord- 
ing to  Lebert,  consist  "of  loose  fibrous  tissue,  made  uj)  of  ]):de,  elastic 
fibres,  enclosing  in  their  large  interspaces  a  homogeneous  granular  sub- 
stance, the  elements  of  which  are  less  adherent  to  each  other  than  in 
deposits  of  true  tubercle."     Lebert  also,  with  other  microscopists,  dis- 


182  SYPHILIS. 

covered  round  granular  cells  in  these  tumors.  According  to  Robin, 
gummy  tumors  "  are  made  up  of  rounded  nuclei  belonging  to  fibro-plastic 
cells,  or  cytohlaistlons ;  of  a  finely  granular,  semi-transparent,  and  amor- 
phous substance  ;  and,  finally,  of  isolated  fibres  of  celluhir  tissue,  a  small 
number  of  elastic  fibres,  and  a  few  capillary  bloodvessels." 

Constitutional  syphilis  is  one  of  the  principal  causes  of  waxy  degenera- 
tion, and  the  spleen  and  liver  of  infants  may  be  enlarged  from  this  cause. 
Dr.  Samuel  Gee  has  expressed  the  opinion  that  in  half  the  cases  of 
hereditary  svphilis  the  spleen  is  enlarged.  (London  Lancet,  April  13, 
1607.) 

Infiltration  of  the  liver  by  fibrous  substance  was  first  noticed  by  Giib- 
ler.  It  is  not  common  in  the  infant.  A  specimen,  showing  this  lesion, 
was  presented  to  the  London  Pathological  Society  in  1866,  by  Dr. 
Samuel  "Wilks.  The  following  remarks  by  Dr.  Wilks  convey  a  good  idea 
of  the  appearance  and  state  of  the  liver  in  syphilitic  cirrhosis :  ''  Having 
dissected  the  bodies  of  several  infants  who  have  died  of  congenital  syph- 
ilis, I  have  found  fatty  livers,  and  an  inilammation  of  the  capsule;  but 
in  only  two  have  I  discovered  adventitious  products  of  a  fibrous  character. 
The  present  example,  however,  corresponds  in  every  particular  with  the 
disease  described  by  Giibler.  It  must  be  distinguished  (at  least  as  fiir  as 
the  naked-eye  appearance  reaches)  from  syphilitic  disease  of  adults, 
of  which  many  specimens  have  been  before  the  Society.  In  these  the 
organ  is  cicatrized  on  the  surface,  and  contains  distinct  nodules  of 
fibrous  tissue  ;  while  in  the  disease  of  children,  as  in  the  present  speci- 
men, the  whole  organ  is  infiltrated  by  a  new  material,  and  it  conse- 
(piently  becomes,  as  described  by  Giibler,  hypertrophied,  globular,  and 
hard,  resistant  to  pressure,  and  even  when  torn  by  the  fingers,  its 
surface  ]-eceives  no  indentation  from  them ;  it  is  also  elastic,  and  when  cut, 
creaks  slightly  under  the  scal]»el.  This  was  the  form  of  disease  in  the 
present  specimen.  It  came  from  a  syphilitic  child,  a  month  old,  in 
whom  the  liver  could  be  felt  enlarged  during  life,  and  when  removed 
weighed  a  pound  and  a  half.  It  was  smooth  on  the  surface,  and  so 
hard  that  it  resembled  rather  a  fibrous  tumor  than  a  liver.  It  is  seen 
that  the  liver  in  the  syphilitic  child  is  liable  to  three  distinct  patho- 
logical processes,  namely,  gummy  tumors,  cirrhosis  or  fibroid  degenera- 
tion, and  waxy  degeneration." 

Syphilitic  perihepatitis  and  periostitis  are  more  rare  in  infimcy  and 
childhood  than  in  adult  life,  but  they  occasionally  occur.  The  late  Sir 
James  Y.  Simpson  considered  pei-itonitis  in  the  Ibctus  one  of  the  results 
of  syphilis,  and  a  cause  of  its  death. 

Osseous  Lesions. — Within  the  last  few  years,  important  discoveries 
have  been  made  in  regard  to  the  effect  of  syphilis  upon  the  nutrition  of 
the  bones  in  children.  In  1870,  Dr.  Wegner,  of  Berlin,  published  his 
observations  of  the  state  of  the  skeleton  in  twelve  syphilitic  children, 
who  Avere  either  stillborn,  or  who  died  within  a  few  days  or  weeks  after 
birth.  He  lound  clear  proof  that  the  syphilitic  dyscrasia  very  frequently 
disturlis  the  nutrition  and  produces  anatomical  changes  in  the  skeleton 
of  the  foetus.  The  following  are  the  lesions,  clearly  referable  to  syphilis, 
which  he  observed  :  periostitis  of  long  bones,  including  the  ribs  ;  soften- 
ing, separation,  and  sometimes  crepitation,  at  the  point  of  union  of  dia- 


OSSEOUS    LESIOXS. 


183 


physis  and  epiphysis ;  chalky  concretions  and  infiltrations  along  the  line 
of  ossification  ;  fatty  degeneration  of  marrow  ;  irregular  formation  and 
distribution  of  spongy  substance  in  the  epiphysis.  These  lesions  were 
not  all  observed  in  each  case,  but  they  occurred  "svith  such  frequency 
that  there  could  be  no  doubt  that  they  were  due  to  the  syphilitic  taint 
of  system.  Confirmatory  observations  also,  in  twelve  cases,  have  since 
been  made  by  Waldeyer  and  Kobner.^ 

Again,  there  is  a  syphilitic  lesion  of  the  bone  in  children,  which  is 
not  usually  present  or  has  not  usually  been  observed  at  birth,  but  is 
developed  in  the  first  weeks  or  months  of  infancy.  The  lesion  alluded 
to  is  a  circumscribed  enlargement  of  one  or  more  bones.  This  has  been 
most  frequently  observed  upon  the  long  bones,  including  the  clavicle 
and  ribs;  but  in  certain' children  it  occurs  upon  other  bones  in  addition. 
In  some  cases  it  is  one  of  the  first  manifestations  of  hereditary  syphilis, 
occurring  even  sooner  than  the  coryza,  while  in  others  several  months 
elapse  before  it  appears.  In  one  case,  reported  by  Dr.  Bulkley,^  of  this 
city,  it  was  first  seen  only  a  few  days  after^ birth,  being  perhaps  con- 
genital ;  while  in  another  case,  in  which  the  enlargement  was  upon 
certain  phalanges,  and  Avhich  is  represented  in  the  accompanying  figure, 
it  appeared  at  the  age  of  twelve  months.  When  it  occurs  upon  a  pha- 
langeal bone,  it  is  designated  dactylitis  sypkilitica. 

Fig.  22. 


The  enlargement,  if  upon  a  long  bone,  ordinarily  begins  at  or  near 
the  point  of  union  of  tlic  diaphysis  witli  tlie  e))ij)hysis.  It  is  located 
upon  the  extremity  of  the  shaft  which  it  encircles,  and  it  extends  over 


*  Rpo  olahorate  papor  by  R.  W.  Taylor,  M.D.,  New  York  JournHl  of  Obstetrics, 
etc.,  .Juh-,  1874. 

'  Kare  Cases  of  Congenital  Syphilis,  New  York  ^led.  Journal,  May,  1874. 


184:  SYPHILIS, 

a  part  or  nearly  the  Avliole  of  the  epiphysis.  It  has  an  elevation  of 
perhaps  one-half  or  three-quarters  of  an  inch  in  typical  cases ;  its  surface 
is  smooth,  or  slightly  undulating,  and  the  skin  over  it,  though  distended, 
has  its  normal  appearance,  and  is  easily  movable,  unless  ulcerations  have 
occurred. 

These  enlargements,  which  result  from  the  specific  inflammation, 
occurrino-  in  the  periosteum  and  the  bone,  may  resolve  under  proper 
treatment ;  but  if  neglected,  and  the  antihygienic  conditions  are  bad, 
deiienerative  changes  may  occur,  ending  in  ulceration  and  destruction 
of  the  diseased  part  to  a  greater  or  less  extent. 

Thouo-h  these  bone  enlargements,  whenever  observed,  should  excite 
suspicions  of  syphilis  as  the  cause,  enlargements  which  present  the 
same  general  appearance  do  occur  from  other  causes.  Such  a  case  was 
observed  by  me  in  the  children's  class  in  the  Outdoor  Department  of 
Bellevue,  and  Dr.  Bulkley  details  another  case  in  his  paper.  In  the 
case  observed  by  me,  the  inflammation  and  enlargement  seemed  to  be 
strumous.  BJiumler  says  :  "  Dactylitis  syphilitica  does  not  ahvays  origi- 
nate in  the  bone  ;  similar  appearances  may  be  produced  through  gum- 
mous  formation  in  the  sheaths  of  the  tendons,  and  in  the  fibrous  structure 
of  the  finijer  ;"  and  again,  "Its  outward  appearance  may  be  produced 
also  by  tuberculosis,  enchondroma,  or  sarcoma  of  the  bone-marrow." 
(Art.  Syphilis,  Ziemssens  EncycL) 

Mr.  J.  Hutchinson,  of  London,  has  called  attention  to  the  fact  that 
hereditary  sypliilis,  having  perhaps  been  manifested  by  the  usual  symp- 
toms during  infancy,  and  then  becoming 
Fig.  23.  latent,  may  give  rise  to  new  symptoms  after 

the  fourth  year.  The  most  noticeable  of 
these  symptoms  is  a  dwarfing  of  the  per- 
mnnent  incisor  teeth,  which  are  rounded 
and  peg-like,  and  their  enamel  notched  at 
the  free  ends  of  the  teeth.  On  account  of 
the  small  size  and  shape  of  the  teeth,  there 
are  interspaces  between  them.  This  abnor- 
mal development  is  most  marked  in  the  central  incisors  of  the  upper 
jaw,  and  in  certain  cases  it  is  limited  to  them,  and  it  never  appears  in 
the  other  incisors  unless  it  does  also  in  them.  Another  symptom,  which 
only  appears  in  hereditary  syphilis,  is  an  interstitial  keratitis  occurring 
on  both  sides,  and  attended  by  the  deposition  of  fibrin  in  the  substance 
of  the  cornea.  In  a  few  weeks  the  inflammation  declines,  but  a  slight 
opacity  of  the  cornea  remains.  The  cerebral  nerves  may  become  af- 
fected, usually  a  single  pair — if  the  auditory,  deafness  resulting  ;  if  the 
optic,  dimness  of  sight.  OccasioniiUy  there  are  other  manifestations  of 
syphilis  in  this  period,  as  enlargement  of  spleen  and  liver,  and  nodes 
upon  the  long  bones. 

PRO(iNOSis. — This  depends  in  great  part  on  the  general  condition  of 
the  patient.  If  there  be  much  emaciation,  and  the  symptoms  indicate 
a  deeply  seated  cachexia,  a  considerable  proportion  perish.  On  the 
other  hand,  if  the  general  health  be  not  greatly  impaired,  although  the 
local  affections  are  pretty  severe,  the  prognosis  with  correct  treatment 
is  good.  The  younger  the  infant,  when  the  symptoms  of  syphilis 
appear,  the  more  unfavorable,  as  a  rule,  is  the  prognosis. 


T  RE  ATM  EXT  185 

Treatment. — Parents  who  beget  syphilitic  chiklren  ought,  from  a 
due  regard  for  their  offspring,  to  make  use  of  antisyjihilitic  remedies, 
although  they  present  in  their  persons  no  evidences  of  syphilitic  taint. 
A  good  prescription  for  the  parents  is  one-sixtieth  of  a  grain  of  cor- 
rosive sublimate  in  the  compound  tincture  of  bark,  given  twice  or  three 
times  daily  f)r  several  weeks.  If  the  father  have  had  syphilis,  both 
parents  should  be  subjected  to  this  treatment,  and  it  may  be  continued, 
at  least  on  the  part  of  the  mother,  during  the  first  months  of  her  gesta- 
tion. So  small  a  dose  of  the  mercurial  does  not,  in  my  opinion  mate- 
rially increase  the  liability  to  miscarry.  There  is  much  more  danger 
of  miscarrying  from  allowing  the  syphilitic  taint  to  remain  uncontrolled. 
Some  prefer  the  use  of  mercurial  ointment  in  the  treatment  of  pregnant 
women  for  syphilis,  in  the  belief  that  it  is  less  likely  to  produce  abor- 
tion. It  is  used  for  this  purj)ose  in  the  proportion  of  one  drachm  to 
the  ounce.  It  is  equally  effectual  in  the  eradication  of  the  syphilitic 
taint  with  the  small  dose  of  corrosive  sublimate  recommended  above  for 
internal  administration  ;  but  it  is  impossible  to  determine  the  quantity 
of  mercury  which  enters  the  circulation  when  inunction  is  employed, 
and  salivation  is  more  likely  to  occur. 

Syphilis  in  the  infant  requires  mercurial  treatment  as  in  the  adult. 
Mercury  may  be  employed  internally  or  by  inunction.  Some  prefer 
inunction  in  the  treatment  of  ordinary  cases  in  the  manner  recom- 
mended by  Sir  Benjamin  Brodie.  I  have  spread,"  says  he,  "  mercurial 
ointment,  made  in  the  ju'oportion  of  a  drachm  to  an  ounce,  over  a  llannel 
roller,  and  bound  it  round  the  child  once  a  day.  The  child  kicks  about, 
and,  the  cuticle  being  thin,  the  mercury  is  absorbed.  It  does  not  either 
gripe  or  purge,  nor  does  it  make  the  gum  sore,  but  it  cures  the  disease. 
I  have  adopted  this  practice  in  a  great  many  cases,  with  the  most  signal 
success."  Trousseau,  on  the  other  hand,  discountenances  the  use  of 
inunction,  as  mercurial  ointment  applied  to  the  skin  produces  irritation, 
and  increases  the  suffering  and  restlessness  of  the  child.  He  prefers 
the  following  solution,  which  is  known  as  Van  Swieten's,  for  internal 
treatment : 

R  . — Hydrarg.  bichlorid 1  part. 

Aquse OCiO  part-!. 

Spis.  lectific. 100  iiirU  — Misce. 

Dose. — One,  or  at  most  two  grammes  (15.434  to  30.868  grains),  in  milk,  daily. 

In  order  to  avoid  the  risk  of  establishinjc  a  diarrhoea,  and  to  leave 
the  stomach  free  for  the  employment  of  other  medicines,  as  cod-liver  oil 
and  the  iodide  of  iron,  I  prefer  and  commonly  prescribe  for  infants  in- 
unction with  the  mercurial  ointment  diluted  with  eight  times  its  (juan- 
tity  of  lard,  cold  cream,  or  vaseline.  It  should  not  be  aj)j)lied  as  a 
jtlaster,  but  a  (piantity  of  the  size  of  u  large  chestnut  should  be  rubbed 
three  times  daily  u)»on  the  neck  or  breast  of  an  infant  of  three  or  four 
months.  For  children  over  the  age  of  eight  or  ten  months,  Van 
Swieten's,  or  one  of  the  following  formulnc  may  be  employed: 

B. — Hydrarg  cum  creta    ....  .     irr   iij-^'j- 

Siiccli.  alb.  .......     7)).  —  .Mi^ce. 

Divid.  in  cliart.  No.  xii.     One  powder  iliree  times  daily. 


186  SYPHILIS. 

Be. — Hydrarg.  chlor.  corros gr.  ss-j. 

Syv.  sarste  comp.         ......     ?ij. 

Aqu£e .^vi'j- — Misce, 

Dose. — One  teaspoonful  three  limes  daily. 

B. — Hyd.  chlor.  corros.      .         .         .         .         .         .  gr.  ss. 

Potas.  iodid.       .         .         .         .         .         .         •  3j- 

Ferri  et  ammon.  citrat.      .         .         .         .         •  .^j- 

Syr.  simplic.       .......  ^vj. — Misce. 

Dose. — One  teaspoonful  three  times  daily  for  a  child  of  3  to  5  years. 

B. — Hyd.  chlor.  corros gr.  j- 

Potas.  iodid. •  jij- 

Syrup,  simplic, 

Aquie aa  ^ij. — Misce. 

Dose. — Six  drops  three  times  daily  for  a  child  of  3  months. 

Mercury,  in  whatever  way  employed,  should  not  be  discontinued 
entirely  till  several  weeks  after  the  syphilitic  symptoms  have  disap- 
peared ;  it  is  proper  to  continue  it  for  a  time,  in  diminished  quantity 
and  fewer  doses,  after  the  health  seems  fully  restored. 

When  the  mercurial  is  omitted,  tonics  are  often  required.  The  pre- 
parations of  cinchona  are  useful  in  certain  cases,  as  are  also  those  of 
iron.  If  the  patient  remain  feeble  and  pallid,  presenting  evidences  of 
struma,  cod-liver  oil  and  syrup  of  the  iodide  of  iron  will  be  found 
beneficial  continued  for  some  weeks  or  months  after  the  mercury  is 
discontinued.  Attention  should  always  be  given  to  cleanliness  and  the 
hygienic  management  of  the  patient.  In  some  instances  direct  treat- 
ment of  the  local  affections  is  serviceable.  To  aid  in  the  cure  of 
syphilitic  coryza,  the  following  ointment  should  be  applied  within  the 
nostrils  by  a  nasal  sponge  three  times  daily : 

B. — Ung.  hydrarg.  nitratis ^ij 

Ung.  zinci  oxidi ^ij. — Misce. 

Recently  I  have  been  in  the  habit  of  employing  Squibb's  oleate  of 
mercury,  two  per  cent.,  for  syphilitic  coryza  of  infants,  and  the  effect 
has  been  satisfjictory.  It  may  also  be  employed  by  cutaneous  inunction 
in  the  treatment  of  the  general  disease. 

Condylomata  or  mucous  patches  seated  upon  the  cutaneous  surface 
should  be  dusted  with  calomel.  At  my  clinique,  in  April,  1871,  a  child 
tAvo  years  and  ten  months  old  was  presented,  with  a  large  condylo- 
matous  outgrowth  near  the  anus.  The  history  of  the  child  showed  that 
in  all  probability  the  disease  had  been  contracted  within  a  year  from 
syphilitic  children  in  one  of  the  public  institutions.  Within  three 
weeks  this  affection  disappeared  by  dusting  upon  it  calomel  once  daily, 
with  appropriate  internal  treatment. 

An  infant  under  the  age  of  twelve  months  should  have  breast-milk, 
and  if  it  present  symptoms  of  syphilis,  and  the  mother  who  suckles  it 
or  the  wet-nurse  have  none,  she  should  be  warned  of  the  danger,  and 
should  watch  for  any  abrasion  upon  her  nipples.  If  an  abrasion  occur 
through  which  her  system  might  be  infected,  or  even  without  an  abrasion, 
it  will  be  safer  to  wash  the  nipples  after  each  nursing  Avith  a  mild  solution 


TREATMENT.  187 

of  corrosive  sublimate.  The  infant  should  be  kept  clean  by  bathing  it 
in  tepid  "svater  twice  daily,  and  excoriations  uj^on  its  lips  or  mucous 
patches  should  be  bathed  before  the  nursing  -with  some  mild  disinfectant 
solution,  as  boracic  acid.  The  best  possible  hygienic  conditions  should 
be  provided  for  the  infant,  since  cachexia  is  commonly  present.  It 
should  be  taken  out-door  frequently  in  suitable  weather,  and  its  removal 
from  the  city  to  the  country,  especially  in  hot  weather,  may  be  advis- 
able. If  the  mother  be  syphilitic,  her  milk  may  be  too  thin  and 
deficient  in  nutritive  properties,  and  if  so,  its  use  should  be  supple- 
mented by  artificial  feeding,  or  a  wet-nurse  should  be  procured.  The 
cachexia  which  remains  after  the  disappearance  of  the  syphilitic  mani- 
festations requires  the  use  of  tonics,  as  cod-liver  oil  and  syrup  of  the 
iodide  of  iron. 

Syphilitic  symptoms  may  reappear  during  childhood.  The  exan- 
themata rarely  appear  at  this  age  when  the  proper  treatment  has  been 
employed  ip.  infancy,  but  condylomata  and  gummy  tumors  may,  and 
they  require  a  return  to  the  mercurial  treatment.  If  the  bones  are 
affected,  the  iodide  of  potassium  is  the  proper  remedy.  It  causes 
manifest  improvement  in  the  disappearance  of  the  periosteal  pains  and 
swelling. 


SECTION  II. 

ERUPTIA'E  FEVERS. 


CHAPTER    I. 

MEASLES. 

The  disease  kno-\vn  in  the  vernacular  as  measles  has  also  the  names 
rubeola  and  morbilli.  It  is  a  common  exanthematic  affection,  occurrino; 
at  any  age,  but  most  frequently  in  childhood.  It  affects  once  the 
majority  of  mankind.  Writers  recognize  three  stages  of  measles : 
first,  that  of  invasion,  which  ends  with  the  appearance  of  the  eruption; 
secondly,  the  eruptive  stage ;  and,  thirdly,  the  stage  of  decline  or  des- 
quamation. 

Etiology. — Micrococci  have  been  found  in  the  blood  of  rubeolar 
patients  by  Coze  and  Feltz.  Keating  also  discovered  them  during  an 
epidemic  of  malignant  measles  (Phila.  Med.  Times,  Aug.  12,  1882), 
and  Ransome,  Braidwood,  and  Vacher  found  them  in  the  breath  of 
patients,  as  well  as  in  their  tissues  (Brit.  Med.  Journ.,  Jan.  21, 
1882).  It  seems  probable  that  they  are  the  specific  principle;  if  so, 
they  remain  dormant  in  the  system  about  twelve  days,  which  is  the 
incubative  period. 

Symptoms. — This  disease  commences  with  such  symptoms  as  usually 
occur  in  mild  but  pretty  general  inflammation  of  the  air-passages, 
namely,  cough,  fever,  anorexia,  and  thirst.  The  eyes  present  a  suf- 
fused, moderately  injected,  and  brilliant  appearance,  and  the  buccal  and 
faucial  surfaces  are  injected.  The  Schneiderian  membrane,  and  that 
lining  the  larynx,  trachea,  and  bronchial  tubes,  ])articij)ate  in  the 
increased  vascularity.  The  cough  at  first  is  dry,  and  sometimes  dis- 
tinctly croupy.  Catarrhal  or  false  croup,  indeed,  is  not  infrequent  in 
the  initial  period  of  measles.  The  cough  is  attended  by  slight  accelera- 
tion of  respiration,  and  by  little  or  no  pain  in  the  respiratory  move- 
ments. If  auscultation  be  practised  at  this  early  stage,  we  observe  the 
vesicular  murmur,  somewhat  harsh  in  character,  and  sometimes  sonorous 
and  sibilant  rfiles.     A  little  later,  riiles  of  a  moist  character  a]ij)car. 

The  patient,  if  old  enough,  commonly  complains  of  headache,  and  of 
dull  pain  in  the  epigastric  region,  or  the  centre  of  the  sternum,  due  to 
the  bronchitis.  With  these  local  symptoms  febrile  reaction  occurs. 
The  temperature  rises  to  about  102°  or  103°,  as  indicated  by  the 
thermometer  in  the  axilla.  The  pulse  numbers  from  110  to  130  per 
minute.  The  febrile  movement  is  greater  than  in  primary  tracheo-bron- 
(188) 


SYMPTOMS.  189 

cliitis,  except  when  the  bronchitis  extends  to  the  bronchioles,  but  it  is 
less  than  in  most  cases  of  scarlet  fever. 

The  fever  in  the  premonitory  stage  of  measles  after  the  first  day  is 
not  uniform.  It  is  attended  by  remissions  and  exacerbations,  the  former 
occurring  in  the  first  part  of  the  day,  the  latter  in  the  evening.  Some- 
times two  exacerbations  occur  in  the  day.  The  face  is  flushed  and 
somewhat  swollen,  especially  during  the  times  of  increase  in  the  fever, 
and  the  child  is  drowsy  or  restless.  Vomiting,  so  common  a  symptom 
in  the  commencement  of  scarlet  fever,  occasionally  occurs  in  measles. 
While  in  scarlet  fever  this  takes  place  in  the  first  twenty-four  hours,  in 
measles  it  takes  place  with  about  equal  frequency  at  any  period  pre- 
viously to  the  eruption.  It  was  present  during  the  first  stage,  sometimes 
almost  as  late  as  the  eruptive  period,  in  thirteen,  and  Avas  absent  in 
twenty-three  cases,  in  which  I  preserved  records  in  reference  to  this 
symptom. 

The  duration  of  the  first  stage  varies  in  different  cases.  It  is  usually 
from  two  to  five  days,  with  an  average  of  about  four.  Occasionally  it 
is  more  protracted  on  account  of  some  disturbance  in  the  economy, 
either  from  exposure  to  cold  or  other  cause,  which  prevents  the  necessary 
afflux  of  blood  toward  the  surface,  and  retards  the  eruption.  In  eighteen 
cases  in  my  practice  in  which  the  duration  of  the  cough  previously  to 
the  appearance  of  the  rash  was  accurately  ascertained,  the  time  varied 
from  one  to  five  days,  with  an  average  of  three  and  one-third;  in  ten 
other  cases  it  had  continued,  the  parents  stated,  about  a  week,  and  in 
five,  from  one  to  two  weeks,  previously  to  the  eruption. 

The  eruption  commences,  when  the  disease  pursues  its  normal  course, 
upon  the  foreliead  and  neck,  then  the  face,  and  gradually  extends  down- 
Avard,  (jcciipying  from  twenty-four  to  thirty-six  hours  in  passing  over 
the  trunk  ami  limbs.  It  appears  first  as  indistinct  red  poiijts,  not  more 
than  a  line  in  diameter,  which  increase  in  size  and  become  more  distinct. 
Tiieir  borders  are  uneven  or  irregular,  or  they  are  finely  notched ;  their 
general  shape  is,  however,  circular,  except  as  two  or  more  unite,  when 
they  may  assume  any  form.  The  crescentic  form  which  writers  describe 
is  due  to  the  union  of  two  points  of  eruption.  The  largest  of  tliese 
spots,  when  tliere  is  no  coalescence,  do  not  exceed  a  ([uarter  of  an  inch 
in  diameter,  and  many  are  much  smaller.  Frequently  in  plethoric 
children,  if  tliere  be  much  fever,  there  is  continuous  redness  over 
several  inches  of  surface.  The  eruption  is  then  confluent.  This  form 
is  often  observed  upon  parts  of  the  surface  where  the  capillary  circula- 
tion is  most  active,  when  it  is  discrete  elsewhere.  In  some  of  these 
cases,  diagnosis  of  measles  from  scarlet  fever  is  attended  with  difficulty. 

The  rubeolous  eruption  is  slightly  elevated,  the  elevation  not  being 
appreciable  to  the  sight,  but  it  can  be  ascertained  by  passing  the  finger 
over  the  skin,  when  roughness  is  felt  at  the  point  of  eruption.  Some- 
times the  elevation,  especially  in  the  commencement  of  the  efliorcscence, 
is  not  apprccial)le,  even  to  the  touch.  The  eruption  is  broad  and  flat, 
never  acuminate,  never  chanj^inii  its  form  to  the  vesicular  or  pustular. 

T  1  •  .  ,  * 

it  disappears  by  pressure,  and  immediately  reappears  when  the  pressure 
is  removed.  It  has  been  compared  in  appearance  to  flea-bites.  Small, 
pointed,  papular,  vesicular,  or  pustular  eruptions  arc  sometimes  seen  in 


190  MEASLES. 

connection  with  those  of  measles,  but  they  are  accidental,  occurring  in 
other  states  of  system,  as  ■well  as  in  measles,  if  there  be  the  same 
augmented  tempei*ature. 

In  the  commencement  of  the  eruptive  period  the  severity  of  the  con- 
stitutional and  local  symptoms  increases.  The  pulse  and  temperature 
correspond  Avith  the  character  which  they  presented  during  the  exacer- 
bations of  the  first  stage.  The  features  arc  slightly  swollen ;  the  eyes 
still  watery  and  sensitive  to  light;  the  conjunctiva,  ocular  and  palpebral, 
and  the  mucous  membrane  of  the  cavity  of  the  mouth  and  of  the  air- 
passages,  continue  injected.  The  tongue  is  covered  with  a  moist  thin 
fur,  and  its  jmpillne  are  prominent,  though  less  so  than  in  scarlet  fever. 
The  cough  continues  frequent,  and  is  seldom  attended  with  much 
expectoration,  in  uncomplicated  cases;  often  there  is  no  expectoration 
whatever.  The  appetite  is  lost,  but  drinks  are  readily  taken  on  account 
of  the  thirst.  Diarrhoea  sometimes  occurs  on  the  first  day  of  the  erup- 
tion, but  it  lasts  only  a  few  hours,  and,  if  the  disease  pursue  its  usual 
course,  abates  of  itself.  With  the  exception  of  this  the  bowels  are 
regular,  or  a  little  constipated  during  the  eruptive  period. 

On  the  second  day  of  the  eruption,  or  sixth  of  the  fever,  the  symp- 
toms begin  to  abate.  The  pulse  is  less  accelerated,  and  the  temperature 
diminishes ;  the  cough  is  less  frequent  and  is  easier,  and  the  flushed 
and  swollen  appearance  of  the  face  declines.  By  the  close  of  the  third 
or  on  the  fourth  day  the  rash  has  disappeared  in  the  order  in  which  it 
extended  over  the  body.  There  only  remain  fixint  maculne,  which  in 
the  course  of  a  day  or  two  fade  completely. 

With  the  disappearance  of  the  rash  the  fever  nearly  or  quite  ceases, 
but  a  slight  and  painless  cough  continues  for  several  days. 

Occasionally  the  eruption  presents  a  livid  appearance;  this  is  tne 
rubeola  nigra,  of  writers.  From  cases  which  I  have  observed,  it  is  my 
opinion  that  this  should  not  be  considered  a  distinct  s])ecies  in  the  vast 
majority  of  patients,  but  that  the  dark  color  is  due  to  internal  inflam- 
mation, usually  capillary  bronchitis  or  pneumonia,  Avhich  prevents  full 
decarbonization  of  the  blood.  Rarely  rubeola  nigra  is  due  to  the 
vitiated  state  of  the  blood,  or  the  malignant  nature  of  the  disease. 
The  course  of  the  eruption  in  this  form  of  measles  is  somewhat  dif- 
ferent; it  continues  longer,  fides  more  slowly,  and  does  not  disappear 
so  readily  on  pressure.  Traces  of  it  are  observed  a  week  or  more  after 
its  first  appeai'ance;  it  is  likely  to  be  fatal.  Measles  may  present  this 
form  from  the  beginning,  or,  commencing  as  vulgaris,  it  may  pass  into 
rubeola  nigra. 

jNIeasles  may  be  irregular  in  form,  but  aberrations  are  less  frequent 
than  in  scarlet  fever.  Writers  describe  measles  without  catarrh,  and, 
on  the  other  hand,  with  catarrh  but  without  the  rash.  But  positive 
diagnosis  in  such  cases  must  be  difficult.  It  is  probable  that  simple 
catarrh  and  roseola  have  sometimes  been  mistaken  for  the  two  forms  of 
irregularity  mentioned;  but  when  a  child,  in  a  family  of  children  affected 
with  measles,  presents  all  the  symptoms  of  that  disease,  except  the 
catarrh  or  except  the  eruption,  the  diagnosis  of  irregular  measles  would, 
as  a  rule,  be  correct. 

Occasionally  the  stage  of  invasion  is  very  short,  or  even  absent.     In 


COMPLICATIONS.  191 

one  case  the  parents  informed  me  that  the  catarrhal  symptoms  began  on 
the  day  when  the  eruption  appeared.  Convulsions  sometimes  occur  at 
the  commencement  of  measles,  as  Avell  as  during  its  progress.  A  single 
convulsive  attack  at  the  commencement  of  measles  is  usually  not  dan- 
gerous ;  "when  repeated,  it  is  more  serious ;  it  is  also  more  serious  Avlien 
it  occurs  in  the  course  of  measles.  In  certain  patients  the  eruption  ap- 
pears in  an  irregular  and  partial  manner,  occurring  perhaps,  at  a  late 
period,  and  indistinctly,  upon  the  trunk  alone,  or  upon  the  trunk  and 
partially  upon  the  legs.  In  many  cases  of  deferred  or  partial  eruption 
there  is  internal  congestion  or  inflammation  of  some  part,  Avhich  causes 
withdrawal  of  blood  from  the  surface,  and  thus  prevents  the  normal 
development  of  the  rash. 

When  the  eruption  disappears  the  third  stage  commences,  that  of  des- 
quamation. It  is  characterized  by  a  scanty  furfuraceous  exfoliation  of 
the  epidermis.  The  desquamation  is  seldom  as  great  as  in  scarlet  fever, 
and  it  occurs  most  where  the  eruption  has  been  thickest  and  the  epider- 
mis most  inflamed.  Exfoliation  occurs  between  the  fourth  and  seventh 
days  after  the  commencement  of  the  eruption,  the  eighth  and  the 
eleventh  of  the  disease.  Frequently  it  does  not  take  place,  or  is  so  slight 
as  not  to  be  observed. 

With  the  disappearance  of  the  rash,  the  symptoms  rapidly  abate.  The 
pulse  becomes  more  natural,  the  tcnij^eraturc  is  reduced,  the  digestive 
organs  return  to  their  normal  state,  and  the  convalescence  is  established. 
The  cough  continues  several  days  after  the  other  symptoms  abate,  but 
it  is  less  and  less  frequent,  and  is  not  painful. 

Complications. — The  complications  of  this  disease  are  important. 
Much  of  the  success  of  the  physician  in  the  management  of  measles  de- 
pends upon  a  correct  diagnosis  and  understanding  of  them.  The  most 
frequent  of  these  complications  arc  bronchitis  and  broncho-pneumonia. 
Slight  bronchitis  is  uniformly  present  in  measles,  but  if  it  increase  so 
as  to  cause  embarrassment  of  respiration,  and  become  a  scource  of  dan- 
ger, it  is  properly  a  complication.  This  complication,  as  well  as  pneu- 
monia, may  occur  at  any  period  of  measles;  but  it  commences  most 
frequently  in  the  first  stage.  Occurring  in  the  first  stage,  it  may  pre- 
vent the  regular  appearance  of  the  rash;  if  in  the  second,  it  often  causes 
retrocession  of  it. 

When  bronchitis  becomes  really  serious,  it.  usually  lias  invaded  the 
minute  bronchial  tubes.  This  disease,  designated  capillary  bronchitis 
or  suflbcative  catarrh,  I  have  elscAvhcre  described.  The  clinical  history 
of  fatal  bronchitis,  as  a  complication  of  measles,  is  as  follows:  Tlie  re- 
spiration, at  first  not  notably  altered,  becomes  l)y  degrees,  accelerated, 
and  tlie  patient  more  and  more  fretful.  The  pulse,  instead  of  becoming 
less  accelerated,  as  after  the  first  days  of  simple  measles,  is  daily 
more  ra|»id,  and  the  respiration  more  fixniueiit  ami  labored.  The  dysp- 
mca  gradually  increases,  the  iiiframammary  region  is  depressed,  during 
each  inspiration,  and  the  su1)crej)itant  rale  is  heai-d  on  both  sides  of 
the  chest.  There  is,  probably,  collapse  or  inflammation  of  some  of 
the  lol)ules.  Finally  the  prolabia  and  fingers  become  livid,  and  death 
occurs  from  apnnca.  Capillary  bronchitis  is  diagnosticated  from  pneu- 
monitis by  the  physical  signs.     It  is  in  the   young  child  more  dan- 


192  MEASLES. 

gerous  than  that  disease,  unless  perchance  the  latter  be  double.  A 
large  proportion  of  those  affected  under  the  age  of  three  years,  die.  The 
anatomical  characters  of  fatal  bronchitis  occurring  in  connection  with 
measles,  I  have  had  an  opportunity  to  inspect.  In  an  infant  who  died 
with  this  complication  in  the  Inftmts'  Hospital  in  the  spring  of  1867, 
there  were  evidences  of  continuous  inflammation  from  the  epiglottis  to 
the  minutest  bronchial  tubes. 

Pneumonia  as  a  complication  does  not  differ  materially  from  the  idio- 
pathic inflammation,  except  that  it  is  moi'o  protracted  and  fatal.  Its 
form  is  in  most  cases  catari'hal,  resulting  from  an  extension  downward 
of  the  bronchitis. 

The  next  most  frequent  serious  comjdication  of  measles  is  entero- 
colitis. This  may  commence  at  any  period  during  the  course  of  the 
disease.  If  the  colon  be  more  especially  the  seat  of  inflammation,  the 
evacuations  contain  mucus  and  blood,  unless  in  young  children,  in  whom 
the  stools,  even  in  severe  colitis,  commonly  have  a  green  color.  The 
anatomical  character  of  this  complication  varies  in  different  cases,  like 
the  idiopathic  form  of  inflammation.  Sometimes  there  is  simple  arbo- 
rescence  of  the  intestinal  mucous  membrane,  with  tumefaction  of  its 
follicles;  in  other  cases,  in  addition  to  increased  vascularity,  the  mucous 
coat  is  softened  and  thickened;  and  in  others  still,  especially  if  the  in- 
flammatory action  have  been  protracted,  ulceration  occurs,  for  the  most 
part,  in  the  site  of  the  solitary  glands.  Exceptionally,  in  fatal  cases  of 
measles  attended  with  diarrhoea,  no  vascularity  is  observed  after  death, 
although  the  intestine  may  be  thickened  and  softened.  In  such  cases 
the  diarrhcea  was  probably  inflammatory,  the  injection  of  the  vessels 
having  disappeared  after  death. 

Severe  and  obstinate  diarrhocal  affections  occurring  with  measles, 
usually  commence  as  the  primary  disease  is  about  declining.  They 
then  become  scqueloe,  ending  fatally  in  many  instances,  especially  in 
the  summer  months,  several  days  or  perhaps  weeks  after  the  disappear- 
ance of  the  eruption.  Diarrhocal  attacks,  occurring  in,  or  previously 
to,  the  eruptive  stage,  are,  as  a  rule,  mild  and  easily  relieved. 

In  some  grave  cases,  measles  have  a  tendency  from  the  first  to  affect 
the  internal  organs  more  than  the  surfiice.  There  can  coexist  bron- 
chitis, pneumonia,  and  entero-colitis,  with  indistinctness  of  the  eruption 
on  the  skin.     Such  complications  render  a  flxtal  result   highly  probable. 

Eclampsia  is  also  an  occasional  very  dangerous  complication.  It 
sometimes  occurs  very  suddenly  and  unexpectedly.  A  child  of  five 
years  in  my  practice,  apparently  progressing  favorably  with  measles, 
was  allowed  to  sit  at  dinner  with  the  family,  suddenly  and  without 
premonition,  eclampsia  occurred,  the  rash  receded,  and  notwithstanding 
vigorous  treatment  death  resulted  in  a  few  hours,  llapidly  develojied 
cerebral  congestion  seemed  to  be  present.  To  prevent  such  a  comj)li- 
cation,  the  patient  should  remain  quiet  in  bed  during  the  eruptive 
stage. 

Another  very  fatal  complication  and  sequel  is  true  croup,  commenc- 
ing when  rubeola  is  beginning  to  decline;  but  it  is  less  frequent  than 
pneumonia  or  entero-colitis.  In  catarrhal  or  false  croup,  which,  as  has 
been  previously  stated,  is  not  infrequent  at  the  commencement  of  measles. 


ANATOMICAL    CHARACTERS,  193 

the  cough  has  a  loud,  ringing  character.  In  true  croup,  on  the  other 
hand,  it  is  hoarse  or  harsh,  and  less  distinct,  on  account  of  the  presence 
of  the  pseudo-membrane  in  the  larynx.  True  croup,  always  a  grave 
disease,  is  more  serious  when  it  occurs  as  a  complication  of  measles  than 
in  the  idiopathic  form,  not  only  because  the  blood  is  vitiated  and  the 
system  reduced  by  the  primary  affection,  but  because  the  inflammation 
of  the  mucous  surface  is  in  general  more  extensive,  as  is  also,  I  believe, 
the  pseudo-membrane.  This  membrane  in  the  croup  of  measles  I  have 
seen  extend  so  far  down  the  air-passages,  that  tracheotomy  could  not 
have  been  attended  by  any  decided  amelioration  of  symptoms.  This 
complication,  though  always  grave,  is  not,  however,  necessarily  fatal. 
I  have  known  cases  recover  by  inhalation  of  spray,  when  for  days  there 
had  been  dyspnoea  and  other  evidences  of  a  pretty  firm  pseudo-mem- 
brane. True  croup  causes  continuation  of  the  fever,  which  had  perhaps 
begun  to  abate. 

Diphtheria,  when  epidemic,  also  frequently  complicates  measles. 
Much  of  the  mortality  from  measles  in  this  qity,  since  the  year  1858, 
was  due  to  this  cause.  In  cases  observed  by  myself,  diphtheria  usually 
besran  while  the  fauces  were  still  inflamed,  and  sometimes  before  the 
eruption  had  begun  to  flide.  The  pseudo-membranous  laryngitis  or 
true  croup  mentioned  above,  is,  in  most  instances,  in  localities  where 
diphtheria  prevails,  a  local  manifestation  of  this  disease. 

These  are  the  most  common  complications  of  measles.  There  ai'e 
others  of  less  frequent  occurrence,  among  Avhich  may  be  mentioned 
stomatitis,  pharyngitis,  and  otitis  sufficiently  severe  to  be  considered 
complications.  Rarely,  also,  purpura,  attended  by  hemorrhages  from 
the  different  mucous  surfaces,  occurs  in  connection  with  measles. 
This  complication  is,  however,  more  frequent  in  certain  other  con- 
stitutional diseases,  as  sciylet  fever,  and  especially  variola. 

It  is  seen  that  the  inllararaations  wliich  are  apt  to  occur  in  the  course 
of  measles  are  chiefly  of  the  mucous  surfaces.  In  scarlet  fever,  on  the 
other  hand,  the  inflammations  are  more  frequently  of  serous  surfaces. 

There  are  other  affections,  originating  in  measles,  which  are  rather 
sequclne  than  complications.  Gangrene  of  the  mouth  is  one  which,  as 
stated  in  another  part  of  this  book,  is  more  apt  to  occur  after  measles 
than  any  other  disease.  After  a  severe  epidemic  of  measles  in  the  New 
York  Foundling  Asylum,  in  1874,  three  cases  of  gangrenous  vulvitis 
occurred  in  those  who  had  been  affected.  Ophthalmia  commencing  in 
measles  ofton  persists  for  wrecks  or  months.  It  may  give  rise  to  granu- 
lation of  the  lids,  and  cases  have  been  reported  of  violent  inflammation 
of  a  purulent  character,  producing  ulceration  of  the  cornea,  and 
destroying  vision.  The  ophthalmia  is  sometimes  very  intractable. 
Inflammation  of  the  Schneidcrian  membrane,  commonly  present  during 
measles,  often  continues  as  a  sequel,  extending  back  as  far  as  the 
Eustachian  tube,  where  it  may  cause  swelling,  with  impairment  of 
hearing,  and  forward  to  the  lip,  where  it  may  produce  chronic  eczema. 

Anatomical  Ciiaracters. — [  have  made,  or  witnessed,  mainly 
in  institutions,  several  post-mortem  examinations  of  those  who  have 
died  in,  or  immediately  after,  an  attack  of  measles.  In  all  there  were 
lesions  due  to  complications.     Indeed,  death  directly  from  measles  is  so 

18 


194  MEASLES. 

rare  that  few  have  had  an  opportunity  of  studying  the  anatomical 
characters  apart  from  the  complications.  In  those  who  have  died 
without  any  obvious  coexisting  disease,  and  these  cases  chiefly  occur  in 
the  malignant  form,  there  has  been  congestion  of  the  internal  organs, 
especially  marked  in  the  lungs,  and  sometimes  the  tissues  appeared 
softened.  The  blood,  also,  in  the  malignant  form,  has  a  darker  hue 
than  natural,  and  ecchymotic  patches  have  been  observed  upon  the 
mucous  surfaces  and  elsewhere,  corresponding  in  character  with  the 
petechiiB  under  the  skin  which  sometimes  occur  in  this  form  of  measles. 
In  cases  resulting  fatally  from  bronchitis  or  pneumonia,  the  bronchial 
glands  are  commonly  tumefied  in  the  same  manner  as  the  mesenteric 
glands  are  enlarged  in  enteritis,  and  the  glands  of  the  mesocolon  in 
dysentery. 

Nature. — Rubeola,  like  the  other  exanthematic  fevers,  is  due  to  a 
materies  morbi,  probably  micrococci,  as  has  been  stated  above.  It  is 
highly  contagious  through  the  air.  It  has  been  inoculated  by  the  serum 
from  vesicles  which  sometimes  occur  in  connection  with  the  rubeolous 
eruption,  and  also  by  the  blood  from  a  patient.  Inoculation  does  not 
appear  to  moderate  the  disease,  and  as  measles,  when  contracted  in  the 
ordinary  way,  is  not  in  itself  dangerous,  but  dangerous  only  from  com- 
plications, inoculation  is  not  performed,  except  as  a  matter  of  scientific 
interest.  The  usual  mode  of  propagation  is  through  the  air.  It  is  com- 
municated both  by  the  breath  and  clothing.  By  fomites  the  virus  is 
sometimes  conveyed  a  long  distance.  Under  whatever  circumstances 
measles  may  occur,  probably  the  specific  principle  has  been  communi- 
cated from  some  infected  person.  We  frequently  meet  cases,  as  one  in 
a  sparsely  settled  district  that  has  come  to  my  knowledge  in  which 
exposure  cannot  be  traced.  Yet  the  immunity  of  certain  islands  for 
centuries,  till  infected  through  commerce,  renders  the  doctrine  of  an 
origin  de  novo  improbable. 

Twelve  to  fourteen  days  elapse  from  the  time  of  infection  to  the  com- 
mencement of  the  eruption.  In  cases  observed  in  the  children's  depart- 
ment of  Charity  Hospital,  the  incubative  period  was  ascertained  to  be 
about  twelve  days.  In  those  who  have  been  inoculated,  this  period  is 
said  to  have  been  about  one  week.  Rubeola  prevails  epidemically,  like 
the  whole  class  of  infectious  diseases,  and  in  different  epidemics  the 
type  may  vary  as  well  as  the  character  of  the  complications. 

Diagnosis. — The  diagnosis  of  measles,  previously  to  the  eruption,  is 
often  difficult.  The  catarrhal  symptoms  then  predominate,  and  these  are 
such  as  may  occur  independently  of  any  constitutional  or  blood  disease. 
The  first  stage,  therefore,  is  not  infrequently  mistaken  for  coryza,  or 
mild  bronchitis.  The  points  of  differential  diagnosis  are  the  suffused 
appearance  of  the  eyes,  the  greater  degree  of  fever  on  the  first  day  than 
would  be  likely  to  arise  from  so  moderate  an  amount  of  local  disease, 
and  morning  remission  and  evening  exacerbation  of  the  fever.  Measles 
in  the  first  stage  has  been  mistaken  for  remittent  fever.  The  catarrhal 
symptoms  should  prevent  such  an  error. 

Sometimes  roseola  closely  resembles  measles  in  appearance,  but  the  rash 
of  roseola  appears  within  a  few  hours  after  the  commencement  of  febrile 
symptoms,  and  almost  simultaneously  over  the  whole  body,  and  without 


TREATMENT.  195 

those  local  symptoms  referable  to  the  mucous  surfaces,  which  characterize 
measles. 

Variola  on  the  first  day  of  the  eruption  has  sometimes  been  diagnosti- 
cated measles.  I  recollect  once  being  called  to  an  infant  with  fatal 
confluent  smallpox,  Avho  was  said  to  have  measles.  A  physician,  a  few 
days  previously,  observing  the  red  points  in  the  commencement  of  the 
eruption,  had  made  this  absurd  diagnosis,  and,  predicting  a  favorable 
result,  had  not  thought  it  necessary  to  repeat  his  visit.  In  case  of  doubt, 
it  is  the  part  of  prudence  to  defer  making  a  positive  diagnosis.  A  few 
hours  suffice  to  show  the  distinctive  characters  of  rubeolous  and  variolous 
eruptions.  But  the  anxiety  of  friends  often  necessitates  the  expression 
of  opinion.  The  absence  or  lightness  of  catarrhal  symptoms,  the  earlier 
appearance  of  the  eruption,  and  its  papular  feel  under  the  finger  in  small- 
pox, enable  us  to  discriminate  between  the  two  diseases  in  the  commence- 
ment of  the  eruptive  stage.  Moreover,  the  symptoms  in  the  initial  periods 
are  different,  as  will  be  seen  in  our  description  of  smallpox. 

Prognosis. — This  is  favorable,  provided  that  no  serious  complication 
arises.  With  internal  inflammatory  complication,  on  the  other  hand, 
the  disease  becomes  much  more  grave.  A  large  proportion  thus  affected 
die.  The  prognosis  is  less  favorable  in  feeble  children  with  scanty 
eruption,  or  an  eruption  appearing  at  a  late  period  and  irregularly.  Dysp- 
nrca,  persistent  and  great  acceleration  of  pulse,  and  coma,  indicate  an 
unfavorable  ending.  Convulsions  occur  much  more  rarely  in  the  course 
of  measles  than  in  scarlet  fever,  and  when  they  occur  after  the  initial 
period  they  usually  end  in  coma  and  death. 

Treatment. — Uncomplicated  rubeola  requires  little  medicinal  treat- 
ment except  to  palliate  symptoms.  The  child  should  be  kept  in  an  airy 
apartment,  at  a  unifoi'm  temperature  of  about  70°.  A  temperature  so 
elevated  as  to  be  uncomfortable  to  the  nurse  is  injurious  to  the  patient. 
But  while  the  popular  idea  is  erroneous,  that  he  should  be  kept  in  a  heated 
atmosphere,  it  is  correct  that  currents  of  air  and  sudden  reduction  of 
temperature  are  dangerous.  A  violent  and  fatal  attack  of  croup  occurred 
in  my  practice  in  a  girl  of  fifteen,  in  consequence  of  exposure  at  an  open 
window  at  the  close  of  the  eruptive  stage.  The  diet  should  be  mild,  and 
for  the  most  part  liquid.  The  patient,  indeed,  refuses  solid  food,  but, 
on  account  of  the  thirst,  takes  li(iuids  more  readily.  Farinaceous  sub- 
stances, with  milk,  afford  sufficient  nutriment  in  ordinary  cases.  If  the 
previous  health  have  been  poor  and  the  vital  powers  reduced,  or  if  there 
be  a  complication,  more  sustaining  diet  is  rc([uired.  Stimulation  by  wine 
or  brandy  is  needed  in  these  cases.  During  the  two  or  three  weeks  suc- 
ceeding an  attack  of  measles,  care  should  be  taken  to  avoid  exposure  to 
cold,  or  clianges  of  temperature,  since  during  this  period  there  is  great 
lialjility  to  inflammations  of  the  mucous  surfaces. 

The  cough  ordinarily  requires  treatment,  inasmuch  as  the  suffering  of 
the  cliild  and  loss  of  sleep  are  largely  due  to  this  symptom.  Demulcent 
drinks,  as  flaxseed  tea,  infusion  of  sli[)pcry-elmbark,  or  solution  of  gum 
Arabic,  are  useful,  to  which,  to  render  them  more  palatable,  lemon-juice 
may  be  added.  A  small  Dover's  powder,  or  the  mistura  glycyrrhiz.v 
composita  of  the  pharmacopoeia,  given  occasionally,  relieves  the  severity 
and  diminishes  the  frequency  of  the  cough. 


196  MEASLES. 

As  the  chief  danger  in  measles  is  from  inflammation  of  the  respiratory 
organs,  local  treatment  directed  to  the  chest  is  important.  The  chest 
should  be  covered  with  oil  silk,  unless  in  the  mildest  cases.  This  in- 
creases the  amount  of  eruption  upon  the  surface  underneath,  and,  I 
believe,  tends  greatly  to  prevent  complication  by  bronchitis  and  pneu- 
monia. If  the  eruption  be  tardy  in  its  appearance,  or  indistinct,  it  is 
well  to  produce  moderate  counter-irritation  by  some  gentle  irritant 
underneath,  as  camphorated  oil,  to  which  one-fourth  part  of  turpentine 
is  added. 

Affections  which  complicate  measles  should  receive,  for  the  most  part, 
such  treatment  as  is  appropriate  for  them  when  idiopathic.  Secondary 
disea-es,  however,  require  sustaining  measures  more  than  primary.  In 
bronchial  and  pulmonary  inflammations,  which,  if  they  occur  early  in 
measles,  prevent  the  regular  appearance  of  the  eruption,  or,  if  in  the 
eruptive  stage,  cause  its  disappearance,  prompt  counter-irritation  over  the 
chest  by  sinapisms  or  otherwise  is  required.  Trousseau  states  that  he 
has  derived  benefit,  in  these  cases,  from  what  he  designates  urtication. 
This  is  pi^oduced  by  stroking  the  chest  two  or  three  times  daily  with  the 
nettle  (urtica  dioica  or  urtica  urens).  This  causes  a  prompt  and  abundant 
eruption,  and  with  a  less  amount  of  suffering  than  one  would  suppose. 
The  fever  abates,  and  the  respiration  becomes  more  natural  in  proportion 
to  the  amount  of  ncttlerash.  On  the  second  day  the  eff"ect  is  less  than  on 
the  first,  and  after  three  or  four  days,  says  Trousseau,  no  further  irrita- 
tion results  from  the  nettle.  When  counter-irritation  is  produced,  by 
whatever  method,  the  chest  should  be  covered  with  a  warm  and  soft 
poultice,  as  the  ground  flaxseed ;  deriv^atives  to  the  extremities  are  useful 
in  such  cases.  In  capillary  bronchitis  and  pneumonia  stimulating  ex- 
pectorants are  re(|uired,  as  carbonate  of  ammonium.  The  following  I 
employ  for  a  child  of  two  or  three  years. 

U . — Tinct.  ipecac,  comp.  (Squibb's  liq.  Dover's  pulv.)  gtt.  viij-xvj  . 

Amnion,  carbonat.       ......  gr.  xvj-^ss. 

Syr.  bal.  tolut. 

Aquffi afi  ,^j. — Misce. 

Dose. — One  teaspooiiful  ever\'  two  or  three  hours. 

Muriate  of  ammonium  is  also  a  good  remedy  in  these  cases,  employed 
in  double  the  dose  of  the  carbonate. 

Quinia  to  reduce  the  fever,  and  digitalis  as  a  heart  tonic,  are  also  very 
useful  in  these  inflammations,  given  alone  or  alternately  with  the  above. 

The  cases  of  gangrenous  vulvitis  alluded  to  above  were  treated  with 
a  flaxseed  poultice,  and  iodoform  dusted  over  the  surface  each  day  or 
second  day,  with  a  satisfactory  result.  As  regards  the  treatment  of 
other  complications,  the  appropriate  measures  are  detailed  elsewhere. 


ETIOLOGY.  197 


CHAPTER  II. 

SCARLET  FEVER. 

It  is  supposed  by  some  who  have  studied  the  history  of  scarlet  fever, 
that  it  is  a  disease  of  ancient  origin,  but  the  descriptions  of  diseases  left 
us  by  the  old  writers,  and  by  those  in  the  Christian  era  until  after 
the  middle  ages,  are  so  obscure,  or  differ  so  widelv  in  the  statements 
made  from  the  S3'mptoms  of  scarlet  fever,  that  the  impartial  critic  fails 
to  find  any  clear  evidence  of  its  occurrence  prior  to  the  last  four  or  five 
centuries. 

The  first  clear  and  undoubted  portrayal  of  this  disease  in  found  in 
the  medical  literature  of  the  sixteenth  century. '  Sydenham  and  his  con- 
temporaries in  the  seventeenth  century  witnessed  epidemics  of  it,  studied 
its  nature  more  thoroughly,  and  consequently  acquired  a  more  accurate 
knowledge  of  it  than  that  possessed  by  their  predecessors.  It  was  in 
this  century  that  measles  and  scarlet  fever  were  differentiated.  During 
the  last  two  hundred  years  scarlatina  has  been  the  subject  of  monographs 
too  numerous  to  mention.  It  has  long  been  regarded  as  one  of  the 
most  important  maladies  of  cliildhood,  on  account  of  its  frequency  and 
the  great  mortality  tliat  attends  it,  so  that  numerous  cases  and  many 
epidemics  are  every  year  related  in  the  medical  journals.  By  this  vast 
accumulation  of  observations  and  the  patient  and  thorough  use  of  the 
microscope  our  knowledge  of  scarlet  fever  has  become  full  and  accurate. 

As  with  most  of  the  infectious  maladies,  scarlet  fever  extended  to  the 
^Vestern  World  through  European  shipping.  It  was  brought  to  Xorth 
America  about  the  year  173;j.  Tardily  it  spread  to  South  America, 
where  it  appeared  in  lS2n,  and  more  recently  it  has  been  established  in 
Australia.     It  entered  Iceland  in  1827,  and  Greenland  in  1S47. 

Etiology. — The  evidence  is  strong;  that  scarlet  fever  does  not  originate 
de  novo — that  it  does  not  spring  from  certain  atmospheric  or  telluric  con- 
ditions, but  is  j)roduced  by  a  definite  specific  princijtle,  since  countries 
have  been  free  from  it  for  centuries  till  it  was  iuq)orted  by  commerce. 
Tliat  it  appears  in  cert'iin  localities  without  any  known  exposure  is 
attributed  to  the  fact  that  the  poison  is  so  subtle  and  transmissible  that 
it  is  conveyed  long  distances  in  articles  of  merchandise,  even  in  small 
packages,  so  that  those  who  chance  to  open  them  or  come  in  contact 
with  them  are  infected.  It  is  believed  that  reailing  matter  transmitted 
through  the  mails  has  in  many  instances  l»cen  the  medium  of  infection. 

The  theory  that  the  acute  infectious  maladies  are  caused  by  micro- 
organisms, or,  as  they  are  now  designated,  microbes,  commonly  dis- 
carded at  first  and  believed  to  be  chimerical,  is  raf)idly  gaining  ground 
in  the  profession,  and  appears  to  bo  fully  established  as  regards  certain 
of  them.  These  parasites,  barely  visihle  under  hiirh  powers  of  the 
microscope,  and  ascertained  to  be  vegetable  ))y  their  l»ehavior  under 
certain  chemical  agents,  exist  in  immense  numbers  in  the  blood,  tissues. 


198  SCARLET    FEVER. 

and  secretions  of  patients  suffering  from  the  infectious  maladies,  espe- 
cially in  the  graver  cases  of  them  ;  and  the  microscope  shows  that 
these  organisms  vary  in  shape  and  appearance  so  as  to  admit  of 
classification. 

The  germ  theory  has  now  become  so  important  that  it  cannot  be 
ignored  in  a  monograph  relating  to  so  important  an  infectious  malady 
as  scarlet  fever.  The  relation  of  microbes  to  the  infectious  diseases  has 
been  made  the  subject  of  investigation  by  Pasteur,  Toussaint,  and 
others  in  France,  and  by  many  in  Germany,  with  most  interesting 
results.  The  belief  held  by  many,  and  which  seemed  very  plausible, 
was  that  the  microbes,  instead  of  sustaining  a  causative  relation  to  the 
maladies  in  which  they  occur,  were  the  result  of  these  maladies — that 
they  sprang  into  existence  in  consequence  of  the  vitiated  state  of  the 
blood  and  tissues,  just  as  fungi  appear  on  decaying  substances  or  as  the 
oidium  albicans  appears  in  certain  morbid  condition  of  the  bucciil  sur- 
face and  secretions.  Obviously,  in  order  to  elucidate  this  matter  and 
determine  the  relation  of  these  parasites  to  the  diseases  in  which  they 
occur,  it  was  necessary  to  experiment  on  animals,  but,  unfortunately,  as 
a  bar  to  successful  experimentation  many  of  the  most  important  infec- 
tious maladies  Avhich  afflict  the  human  race,  as  typhus  and  typhoid 
fevers,  the  marsh  fevers,  and  syphilis,  do  not  occur  in  animals,  or  they 
occur  in  a  changed  and  mitigated  form.  Others,  however,  can  be  pro- 
duced in  their  typical  character  in  animals,  as  diphtheria,  and  others 
still  originate  in  animals  and  are  transmitted  from  them  to  man,  as 
anthrax  or  splenic  fever  of  the  herbivora,  and  liydrophobia.  Very  in- 
teresting and  important  results  have  been  produced  by  experimental 
researches  Avith  the  microbes  of  certain  of  these  diseases,  which,  if 
applicable  to  the  common  and  fatal  infectious  maladies  of  an  analogous 
nature  in  man,  may  yet  result  in  immense  benefit  in  mitigating  the 
virulence  of  those  affections  which  are  the  scourge  of  childhood,  and 
which  sensibly  diminish  the  increase  of  population.  It  has  been  found 
possible  to  cultivate  the  microbes  contained  in  the  blood,  tissues,  and 
secretions  in  certain  of  the  infectious  diseases,  and  after  a  series  of  culti- 
vations, so  that  these  organisms  are  far  removetl  from  the  animal  sub- 
stance which  contained  them,  and  with  which  they  were  so  intimately 
associated  in  the  individual,  they  have  been  employed  for  inoculation — 
with  this  important  result,  that  the  primary  disease  was  reproduced. 
Tliis  seems  to  indicate  beyond  question  the  causative  relation  of  these 
parasites  to  the  diseases  in  which  they  occur.  Experiments  with  the 
result  which  I  have  stated  have  been  made  with  the  microbes  of  splenic 
fever,  chicken  cholera,  murrain,  and  certain  otlier  maladies. 

Pasteur  employs  as  the  media  for  cultivation — (1)  urine  neutralized 
by  a  few  drops  of  potash  solution;  (2)  a  liquid  prepared  by  boiling  for 
twenty  or  thirty  minutes  the  yeast  of  beer  in  water,  neutializirig  and 
filtering;  and  (o),  chicken  tea,  prepared  by  boiling  equal  parts  of  water 
and  the  lean  of  muscles  a  quarter  of  an  hour,  filtering  and  neutralizing. 
A  small  drop  of  infected  blood  is  placed  in  the  liquid  of  cultivation,  and 
the  microbes  which  it  contains  multiply  so  abundantly  that  the  liquid 
becomes  turbid  in  a  short  time,  and  they  are  found  in  all  parts  of  it. 
A  drop  of  this  liquid  is  added  to  another  portion  of  the  medium,  and 


ETIOLOGY.  199 

this  also  soon  becomes  turbid  from  tbe  immense  development  of  organ- 
isms "which  have  the  same  microscopic  appearance  and  character  as 
those  in  the  drop  of  blood.  The  process  is  repeated  many  times,  until 
the  microbes  are  far  removed  from  their  original  source  in  the  blood  and 
tissues,  and  a  drop  of  the  last  cultivation,  whether  it  be  the  fiftieth  or 
the  hundredth,  is  inserted  under  the  skin  of  a  healthy  animal  selected 
for  the  experiment.  If  it  be  true,  as  stated  by  the  experimenters,  that 
the  orio-inal  disease  is  thus  reproduced  with  the  microbes  of  at  least  three 
or  four  distinct  maladies,  this  age  is  distinguished  by  one  of  the  most 
important  discoveries  ever  made  in  pathological  studies.  It  remains  to 
determine  whether  this  great  discovery  is  of  general  applicability  to  the 
infectious  diseases  with  which  man  is  afflicted.  If  so,  it  is  not  improb- 
able that  we  are  on  the  eve  of  finding  a  method  by  which  some  at  least 
of  these  maladies  may  be  prevented  or  mitigated,  as  smallpox  has  been 
since  the  time  of  Jenner.  The  result  of  exj^eriments  made  by  Pasteur 
with  the  microbes  of  tliat  fatal  malady  of  the  herbivora,  known  under 
the  various  names  of  splenic  fever,  anthrax,. wool-sorter's  disease,  and 
charbon,  encourages  this  belief.  Originating  among  the  herbivorous 
animals,  it  has  in  many  instances  been  contracted  by  individuals  who 
have  rapidly  perished.  Many  engaged  in  assorting  alpaca  and  mohair 
liave  lost  their  lives  by  it,  some  with  all  the  symptoms  of  profound 
blood-poisoning,  without  external  lesions,  and  others  with  redness  and 
swelling  at  some  point  of  infection  where  a  sore  or  abrasion  existed, 
but  with  speedy  blood-contamination. 

The  microbe  of  this  malady,  the  bacillus  anthracis,  occurs  in  the  form 
of  straight  filaments  with  little  movement  or  only  with  oscillation,  and 
producing  bright-shining  s})ores.  Now  comes  a  very  interesting  and 
important  result  of  experimentation:  Pasteur  states  that  if  several  days 
elapse  between  the  cultivations  the  virulence  of  the  parasite  diminishes,  so 
that  he  has  been  able  to  produce  by  inoculation  with  it  a  mild  and  never 
fatal  form  of  charbon,  which  aflibrds  immunity  in  the  animal  from  any 
subsequent  attack.  This  opinion  was  sustained  by  a  trial  ex])eriment 
on  sixty  sheep.  Toussaint  and  Chaveau  claim  that  they  ])roduce  a 
similar  attenuation  of  the  virus  by  defibrinating  infected  blood,  heating 
it  to  r>r)°  C.  (131°  F.),  and  filtering  it.  These  experiments  awaken  the 
hoj)e  that  the  time  will  come  when  the  acute  infectious  maladies  in  man, 
scarlet  fever  among  others,  will  be  rendered  less  virulent.  That  one  of 
them,  to  wit,  smallpox,  has  for  nearly  a  century  been  under  our  control 
certainly  encourages  the  belief  that  there  is  some  way  to  mitigate  others 
of  the  same  class  which  are  equally  fatal  if  not  so  loathsome. 

As  yet,  observers  do  not  agree  in  regard  to  the  parasite  which  is  snp- 
y)Osed  to  sustain  a  causative  relation  to  scarlet  fever.  Klel)s  states  that 
it  is  jiighly  |)r()bable  that  both  measles  and  scarlet  fever  are  produced 
by  micrococci,  and  lie  has  sketched  the  design  and  described  the 
development  of  a  microbe  which  he  designates  the  Monas  scarlatiiiosum. 

1'he  London  Medical  Timrs  and  Gazette  for  Jan.  28, 1882,  contains 
an  account  of  the  supposed  discovery  of  the  scarlatinous  microbe  bv 
Ekhind,  of  Stockhohn,  an  authority  in  the  microscopic  <'xaniination  of 
j)ar:isites.  lie  says  tiiiit  scarlet  fi'vcr  is  riircly  absent  from  the  Swedish 
capital  and  from  the  barracks  and  dwellings  on  the  isle  of  iSkeiijjshulm. 


200  SCARLET    FEVER. 

In  the  urine  of  scarlatinous  patients  lie  lias  constantly  found  a  pro- 
digious number  of  discoid  corpuscles,  oval  or  round,  their  diameter 
being  less  than  Yo^y^  millimetre,  and  from  ^^^  to  j\  that  of  a  redl)lood- 
cell.  They  are  colorless  or  yellowish-Avhite,  surrounded  by  a  distinct 
cell-wall,  each  containing  a  well-defined  nucleus  of  a  deeper  hue.  Some- 
times one  sometimes  more  of  them  are  seen  in  the  field  of  the  micro- 
scope. They  exhibit  rotatory  or  oscillatory  movements,  especially  ob- 
served when  a  drop  of  water  is  added  to  the  fluid.  They  multiply,  as 
Eklund  has  frequently  seen,  by  fission — first  in  the  microbes,  next  in 
the  nucleus,  and  lastly  in  the  cell-wall,  lie  cannot  say  whether  they 
develop  into  a  mycelium.  At  any  rate,  the  development  of  fine  fila- 
ments seems  to  be  exceptional.  He  has  never  seen  them  adhere  in 
moniliform  chains  nor  massed  as  zoogliTca.  He  considers  them  to  be 
veritable  schizomycetcs,  and  proposes  tlie  name  Plox  scindens. 

Eklund  asserts  that  he  has  found  these  organisms  in  vast  numbers 
in  the  soil-  and  ground-water  of  the  isle  of  Bkeppsholm,  in  the  mud 
of  the  trenches  dug  for  the  water-mains,  and  in  the  greenish  mould 
upon  the  walls  of  the  old  barracks,  where  scarlet  fever  was  most  rife. 
He  states  that  scarlet  fever  has  occurred  in  children  after  drinking  milk 
mixed  with  the  ground-water  of  tlie  island,  and  he  observed  a  case  which 
folk)wed  innnersion  in  one  of  the  trenches  of  the  island  and  the  drying 
of  the  clotiies  in  a  small  room.  In  another  instance,  scarlet  fe^er  broke 
out  in  a  block  immediately  after  exposure  of  the  ground-water  by  exca- 
vations. 

It  is  evident  that  the  discovery  of  this  microbe  under  such  circum- 
stances does  not  prove  that  it  is  tlie  cause  of  the  disease.  This  can  only 
be  determined  by  inoculation,  or  by  experiments  which  furnish  the  con- 
ditions of  scientific  exactness.  Although  great  progress  has  been  made 
in  parasitology  during  the  last  decade,  it  is  evident  that  several  yeai'S 
of  observation  and  experimentation  must  elapse  before  it  is  clearly  and 
definitely  ascertained  whether,  or  to  what  extent,  microbes  cause  scarlet 
feve^  and  the  other  exan thematic  fevers  with  which  it  is  classified. 

Whether  the  specific  principle  of  scarlet  fever  be  a  microorganism  or 
a  chemical  substance,  its  mode  of  action  and  effects  have  been  ascertained 
by  clinical  observations.  Without  doubt  it  commonly  enters  the  system 
by  the  breath,  but  it  may  enter  in  the  ingesta,  and  it  infects  the  blood. 
That  it  resides  in  the  blood,  has  been  ascertained  by  inoculation  with 
this  lirpiid,  ))y  which  scarlet  fever  has  been  reproduced  in  its  typical 
form.  From  the  blood  it  enters  the  tissues  and  secretions.  Hence 
handkerchiefs  or  linen  containing  the  saliva  or  mucus  of  a  patient,  the 
epidermic  scales  shed  abundantly  in  the  desquamative  period,  and  prob- 
ably also  the  urinary  and  fecal  evacuations,  contain  the  poison,  so  as  to 
be  highly  infectious.  Even  the  discharge  of  a  scarlatinous  otorrhoca  is 
thought  by  some  to  be  contagious  for  a  considerable  time. 

Scarlatina  is  communicable  not  only  by  direct  exposure  to  a  patient, 
but  also  by  exposure  to  objects  whicli  hap])en  to  be  in  his  room  during 
his  illness,  and  to  which  the  poison  becomes  attached,  such  as  clothing, 
books,  and  toys;  small  packages,  as  we  have  stated  above,  sometimes 
convey  and  disseminate  the  contagious  principle. 

In  Enjiland  observations  have  been  made  which  show  that  scarlatina 


ETIOLOGY.  201 

has  been  communicated  by  infected  milk.  The  disease  occurred  in  the 
family  of  a  milkman,  and  the  milk,  before  it  was  distributed,  remained 
for  a  time  in  a  kitchen  Avhich  had  been  occupied  by  the  patients.  This 
milk  was  taken  by  twelve  families,  and  in  six  of  these  the  disease 
occurred  almost  simultaneously  at  a  time  when  few  cases  were  occurring 
in  the  locality.  There  had  been  no  direct  exposure  to  the  carrier  of  the 
milk  nor  to  members  of  the  affected  fiimily  (Taylor).  In  another 
instance  a  woman  and  her  son  had  scarlet  fever  while  they  were  serving 
milk  to  several  families,  and  the  disease  apj^eared  in  all  these  families 
except  one,  which  consisted  of  old  people  (Bell).  It  is  known  that 
milk  absorbs  volatile  substances  so  as  to  be  flavored  by  them,  as  is 
shown  in  the  experiment  of  placing  it  in  an  open  vessel  in  a  box  with  a 
pineapple  ;  and  it  may  in  a  similar  manner  become  infected  by  the 
specific  principle  of  scarlet  fevei*,  or  it  may  be  infected  by  detached 
particles  of  e])iderrais ;  Avhich  is  not  improbable  when  one  convalescing 
from  scarlet  fever  is  allowed  to  milk  the  cows  or  prepare  the  milk  for 
distribution. 

The  scarlatinous  virus  surpasses  that  of  any  other  eruptive  fever 
except  smallpox  in  its  tenacious  attachment  to  objects  and  its  por- 
ta))ility  to  distant  localities.  Hence  in  the  literature  of  the  disease  are 
the  records  of  many  cases  in  which  the  poison  was  conveyed  long  dis- 
tances, retainino;  its  virulence  to  the  full  extent  and  causing;  an  outbreak 
of  the  malady  in  the  localities  to  which  it  was  carried.  In  Ncav  York, 
so  frequently  has  scarlet  fever  as  well  as  measles  and  diphtheria  been 
contracted  from  the  persons  or  clothing  of  well  children  Avho  come  from 
infected  houses,  that  the  Health  Board  now  exclude  from  the  public 
schools  all  children  who  come  from  such  houses,  even  though  they  live 
on  separate  floors  from  those  occupied  by  the  sick.  In  one  instance 
that  came  under  my  notice  a  washerwomen  whose  child  had  scarlet 
fever  communicated  the  disease  to  an  infant  in  the  household  where  she 
was  employed,  by  placing  her  shawl  over  the  cradle  in  which  it  was 
lying.  A  ])bysician  of  my  acquaintance  went  from  a  scarlet-fever 
patient  to  a  family  several  streets  distant,  and  tot)k  one  of  tlieir  children 
U))on  his  lap.  After  the  usual  incubative  period  this  child  sickened 
with  a  fital  form  of  the  malady,  and  the  remaining  children  of  the 
household  were  in  time  affected.  In  New  York,  scarlet  fever  has 
seemed  to  me  to  be  not  infVe(piently  communicated  through  school 
books,  which,  profusely  illustrated  by  pictures  and  rendered  attractive 
to  the  young,  are  often  allowed  to  lie  uj)()U  the  bed  of  a  scarlatinous 
])atient  and  be  handled  by  him  during  convalescence,  or  even  during 
the  course  of  the  fever  if  it  be  mild.  The  young  librarian  of  the  cir- 
culating library  of  a  Sunday-school,  whose  pui)ils  came  largely  from  the 
tenement  houses,  was  occupied  a  considerable  part  of  a  day  in  covering 
and  arranging  the  l)ooks.  After  about  the  usual  incubative  period  of 
scarlet  fever  he  sickened  with  the  disease.  His  two  sisters  were  imme- 
diately removed  to  a  rural  township  three  hundred  miles  away,  and  to 
an  isolated  house  where  scarlatina  had  never  occurred.  About  one 
month  after  his  recovery,  ami  after  his  room  had  been  disinfected  by 
burning  sulphur  and  his  bedclothes  and  linen  ha<l  been  thoroughly 
washed,  and  all  articles  suspected  to  hold  the  poison  had  been  either 


202  SCARLET    FEVER. 

disinfected  or  destroyed,  the  brother  visited  his  sisters  in  the  country. 
Three  weeks  subsequently  to  his  arrival  one  of  these  sisters  sickened 
with  scarlet  fever,  and  a  week  later  the  other  also.  It  seems  that  the 
exposure  must  have  occurred  several  days  after  his  arrival  in  the  country 
from  some  book  or  other  infected  article  in  his  possession.  About  two 
months  elapsed  after  the  hist  case ;  the  family  had  returned  to  the  city, 
the  infected  room  in  the  country-house  had  been  thoroughly  fumigated 
by  burning  sulphur  from  morning  till  evening,  when  a  little  girl  from 
an  inland  city  remained  a  few  days  in  this  house,  and  probably  often 
entered  the  room  Avhere  the  young  ladies  had  been  sick.  In  a  few  days 
she  also  sickened  with  a  fotal  form  of  scarlatina.  Such  histories  and 
experiences  are  not  infrequent.  They  are  common  during  epidemics 
of  scarlet  fever.  They  indicate  an  extraordinary  attachment  of  the 
scarlatinous  poison  to  objects,  and  show  that  it  is  not  gaseous  nor 
readily  volatilized. 

A  striking  example  of  this  fixity  of  the  poison  occurred  in  the  prac- 
tice of  the  late  Kearney  Rogers,  formerly  a  prominent  and  much 
esteemed  surgeon  of  New  York  City.  Six  children  in  a  family  had 
scarlet  fever.  Three  and  a  half  months  subsequently  another  child, 
living  at  a  distance,  was  allowed  to  return  home  and  occupy  the  apart- 
ment in  which  the  sickness  had  occurred.  One  week  subsequently  to 
the  date  of  the  return  this  child  sickened  with  the  same  malady. 
Elliotson  states  that  a  patient  with  scarlet  fever  was  admitted  into  one 
of  the  wards  of  St.  Thomas's  Hospital,  and  for  two  years  subsequently 
young  persons  who  were  admitted  into  the  ward  were  apt  to  take  the 
disease.  Richardson,  of  London,  relates  the  following  experiences  of  a 
family  whom  he  attended  in  the  rural  district :  "At  a  short  distance 
from  one  of  our  villaegs  there  Avas  situated  on  a  slight  eminence  a  small 
clump  of  laborers'  cottages,  with  the  thatch  peering  down  on  the  beds 
of  the  sleepers.  A  man  and  his  wife  lived  in  one  of  these  cottages 
with  four  lovely  children.  The  poison  of  scarlet  fever  entered  the  poor 
man's  door,  and  at  once  struck  down  one  of  the  flock."  The  remain- 
inij  children  were  now  removed  some  miles  awav,  and  after  several 
weeks  one  of  them  was  allowed  to  return.  With  twenty-four  hours  it 
also  took  the  disease,  and  quickly  died.  The  Avails  of  the  cottage  were 
noAV  thoroughly  cleaned  and  Avhitewashed,  the  floors  scoured,  and  all 
the  Avearing  apparel  either  destroyed  or  Avashed.  Four  months  elapsed 
after  the  last  sickness  Avhen  one  of  the  remaining  chihlien  returned. 
"He  reached  his  father's  cott;ige  early  in  the  morning;  he  stenied  dull 
the  next  day,  and  at  midnight  I  Avas  sent  for,  to  find  him  also  the 
subject  of  scarlet  fever.  The  disease  again  assumed  the  malignant 
type,  and  this  child  died."  Richardson  believes  that  the  contagion  was 
attached  to  tlie  thatch,  Avhich  could  not  be  thoroughly  disinfected.  The 
fact  of  this  remarkable  lonix-continued  attachment  of  the  poison  to 
objects,  indicating  by  this  fixity  that  it  is  a  solid,  is  consonant  with  the 
theory  that  it  is  an  organism. 

Incubative  Period. — The  duration  of  the  incubative  period  varies 
in  different  cases.  It  is  sometimes  less  than  twenty-four  hours,  as  in 
the  above  case  reported  bv  Etchardson;  in  the  folloAving  Avcll-known 
case,  observed  by  Trousseau,  it  was  one  day.     A  girl  arrived  in  Paris 


INCUBATIVE    PERIOD.  203 

from  Pau,  -where  there  was  no  scarlet  fever,  and  occupied  the  same 
apartment  \\ith  her  sister,  Avho  Avas  sick  Avith  this  disease.  Twenty -four 
hours  after  her  arrival  she  also  was  attacked  with  the  same  malady. 

Russeberger  attended  a  child  who  was  ex})osed  at  noon  to  scarlet 
fever,  and  took  the  disease  on  the  following  night.  B.  W.  Richardson 
[Clinical  JSssaj/s,  1861,  vol.  i.  p.  94)  gives  his  own  experience.  He 
had  applied  his  ear  to  the  chest  of  a  patient  suftering  from  scarlet  fever, 
and  was  conscious  of  a  peculiar  odor  emitted  from  the  patient.  He  Avas 
immediatelv  nauseated  and  chilly,  and  from  that  moment  he  dated  the 
berrinnins  of  an  attack  of  scarlet  fever.  In  the  Transactions  of  the 
Clinical  Society  of  London,  vol.  ix.,  18^8,  the  late  Charles  Murchison 
gives  the  statistics  of  75  cases,  showing  the  incubative  period,  as  follows: 

In 


4  cases 

it 

was 

not  more  than 

..... 

24  hours. 

2     " 

" 

30      " 

3     " 

t( 

36      " 

4     " 

(1 

. 

40      " 

1     " 

u 

..... 

41      " 

4     " 

(( 

.     '    . 

58      " 

1     " 

11 

54      " 

1     " 

<( 

n  davs. 

31  cases 

it 

was 

within 

(time  not 

accurately  ascertained) 

4"     "" 

2  cases 

the  incubulion  did  not  ( 

exceed    .... 

4,V     " 

17     " 

;( 

II 

II 

5       " 

2     " 

11 

a 

" 

6       " 

In  three  cases  Murchison  believes  that  the  incubation  Avas  precisely 
fixed  at  thirty-six  hours,  three  days,  and  four  and  a  half  days. 

Watson  says  that  a  man  reached  Devonshire  on  mid-day  to  see  his 
daughter,  avIio  had  scarlet  fever.  Tavo  days  later  he  Avas  also  attacked. 
Rehn  saAV  a  child  who  Avas  attacked  tAvo  days  after  its  grandmother 
returned  from  a  case  of  scarlet  fever;  and  Zengerle,  a  girl  of  ten  years, 
residing  at  Wangen,  Avhere  there  was  no  scarlet  fever,  Avho  took  the 
disease  tAvo  days  after  her  mother  had  returned  from  visiting  a  family 
affected  Avith  it.  Loochner  states  that  a  boy  aged  four  and  a  half  years 
was  attacked  one  and  a  half  days  after  admission  into  the  infected  Avards 
of  a  hospital.  Armistead,  in  his  annual  report  on  the  health  of  the 
NcAvmarket  rural  district,  states  that  three  children,  coming  from  a  dif- 
ferent part  of  tlie  district,  visited  Westley,  and  stayed  next  door  to  a 
child  Avlio  liad  scarlet  fever  six  Aveeks  jireviously,  and  avIio  Avas  allowed 
to  jiiay  Avith  these  cliildren  on  the  evening  of  August  loth  and  morning 
of  the  14tli.  The  family  then  returnc^d  home,  and  on  the  iSth,  four 
days  after  the  exposure,  all  three  children  sickened  Avith  scarlet  fever 
{Brit ink  Medical  Journal,  September  30,  1882). 

Ordinarily,  therefore,  the  incubative  period,  though  varying  in  dif- 
ferent cases,  is  Avithin  six  days.  Many  cases,  however,  occur  in  Aviiich 
it  seems  to  be  longer.  Thus,  in  my  practice,  scai'let  fever  appeared  in 
a  family  on  April  l!(),  1882.  I'he  patient  Avas  immediately  reiiiove<l  to 
the  third  iloor  and  the  other  children  to  the  basement.  AH  communi- 
cation betAveen  the  infected  room  and  the  basement  Avas  forbidden,  but 
on  May  8th,  tAvelve  days  after  the  se|)aration,  (»ne  of  these  children 
sickened  Avith  tlu;  dise.ise.  Many  observers,  among  Avhom  may  he 
mentioned  Niemeyer  and  Copland,  believe  that  the  incubative  period 


204  SCARLET    FEVER. 

may  be  longer  than  one  week,  but,  on  account  of  the  subtlety  of  the 
poison  and  the  many  modes  of  transmission,  it  is  possible  that  in  the 
instances  of  an  apparently  long  incubative  period  there  Avcre  other  and 
unsuspected  exposures.  When  scarlet  fever  has  been  communicated  by 
inoculation,  as  in  the  experiments  of  llostan  and  others,  the  incubative 
period  has  been  about  seven  days,  but  Gerhardt  states  that  a  man  was 
attacked  four  days  after  an  abscess  was  opened  by  a  knife  used  upon  a 
scarlatinous  patient.  This  variation  in  the  incubative  })criod,  which 
also  occurs  in  some  other  infectious  diseases,  as  di})htheria,  is  probably 
due  mostly  to  individual  differences,  some  being  more  susceptible  than 
others;  but  it  may  be  due  partly  to  those  obscure  meteorological  con- 
ditions which  we  designate  the  epidemic  influence.  Probably,  as  a  rule, 
when  the  disease  is  quickly  developed  after  exposure,  the  attack  is  more 
severe  than  when  several  days  elapse. 

Contagiousness. — The  area  of  the. contagiousness  of  scarlet  fever  is 
small.  It  apparently  embraces  only  a  few  feet.  Therefore,  close 
proximity  is  the  necessary  condition  of  its  propagation.  Hence  many 
who  are  exposed,  particularly  of  those  who  are  remotely  exposed,  do  not 
contract  the  disease.  There  is  also  an  idiosyncrasy  in  some  children,  so 
that  they  resist  infection  even  Avhen  re])catedly  and  closely  exposed.  In 
the  New  York  Medical  Record  for  March  23,  1878,  C.  E.  Billington 
states  that  of  90  children  in  26  families  who  were  exposed  to  scarlet 
fever,  43  contracted  the  disease  and  47  escaped;  whereas,  as  is  well 
known,  comparatively  few  unprotected  children  escape  pertussis,  variola, 
varicella,  or  measles  if  exposed  to  either  of  these  diseases.  By  strict 
isolation,  therefore,  tlie  spread  of  scarlet  fever  is  more  easily  prevented 
than  that  of  most  other  acute  infectious  maladies.  In  the  New  York 
Foundling  Asylum  for  a  number  of  years  children  with  scarlet  fever 
were  isolated  in  a  small  room  attached  to  one  of  the  wards.  The  door 
between  the  two  rooms  was  closed,  and  not  opened  during  the  con- 
tinuance of  the  sickness.  Entrance  into  the  small  room  was  through 
another  door,  and  a  nurse  Avas  assigned  to  the  scarlet-fever  cases,  with 
strict  directions  that  she  should  not  mingle  with  the  other  children. 
These  simple  precautions  were  found  sufficient  in  the  various  epidemics 
of  scarlet  fever  which  occurred  in  the  city  to  prevent  the  spread  of  the 
malady  through  this  institution ;  whereas,  similar  measures  were  much 
less  effectual  in  arresting  the  spread  of  measles  and  pertussis.  Conse- 
quently, an  outbreak  of  scarlet  fever  in  this  institution  was  usually 
limited  to  a  few  cases,  while  the  extension  of  measles  and  pertussis  was 
arrested  with  difficulty  till  a  more  efficient  quarantine  was  established. 

Variations  in  Type. — The  type  of  scarlet  fever  varies  greatly  in 
different  epidemics,  and  frequently  also  in  cases  which  occur  in  the  same 
epidemic,  even  in  the  same  family.  One  child  may  have  scarlatina  so 
mildly  tliat  little  treatment  is  required  and  convalescence  soon  begins, 
while  another  has  the  malignant  form,  and  soon  succumbs,  notwith- 
standing the  prompt  employment  of  the  most  efficient  and  ai)propriate 
measures.  Ordinarily,  however,  if  the  first  case  in  a  family  be  very 
severe,  subsequent  cases  will  present  a  similar  type;  but  there  are 
notable  exceptions.  This  variation  in  type  in  different  years  and  dif- 
ferent epidemics   is   probably   not    equalled   in   any    other    infectious 


SURGICAL    AND    OBSTETRICAL    SCARLATIXA.  205 

malady.  .Consecutive  epidemics  may  present  this  variation,  or  the 
same  type  may  continue  for  a  series  of  years,  and  then,  from  some 
unknown  cause,  change  to  one  milder  or  more  severe.  In  Eno-land, 
durincr  Svdenham's  life,  scarlet  fever  was  so  mild  that  he  regarded  it  as 
a  trivial  affection,  requiring  little  attention,  like  rotheln  of  the  present 
time,  but  after  the  death  of  Sydenham,  Morton  and  his  contemporaries 
in  London  found,  to  their  sorrow,  that  the  type  of  scarlet  fever  was 
very  different  from  that  described  by  Sydenham's  pen.  The  late  Dr. 
Graves,  of  Dublin,  and  his  contemporaries  treated  a  mild  type  of  scarlet 
fever  with  a  very  small  percentage  of  deaths — much  less  than  that 
during  the  preceding  generation — and  they  attributed  their  success  to 
their  greater  knowledge  and  more  appropriate  use  of  remedies  than 
their  ancestors  possessed  and  employed.  By  and  by  the  type  changed, 
the  mortality  of  former  years  was  restored,  and  they  discovered  that 
their  previous  success  in  saving  life  had  been  due  not  to  their  skill,  but 
to  the  mild  form  of  the  malady.  A  distinguished  physician  of  New 
York  treated  more  than  fifty  cases  of  scarlet  fever  in  one  of  the  insti- 
tutions without  a  single  death.  A  few  months  afterward  the  type  of 
the  malady  changed,  and  his  own  son  perished  from  it. 

Surgical  and  Obstetrical  Scarlatina. — After  surgical  opera- 
tions, and  sometimes  in  surgical  cases  not  requiring  operative  measures, 
a  scarlatinous  efflorescence  occasionally  appears  upon  the  whole  or 
nearly  the  whole  body,  and  remains  for  several  days.  The  following 
were  cases  of  the  kind  alluded  to.  They  occuri'ed  in  Guy's  Hospital, 
and  were  published  by  H.  G.  Howse  in  Gwfs  Hospital  Reports  for 
1879 :  On  March  15,  1878,  Jacobson  performed  osteotomy  upon  a 
child  suffering  from  extreme  rachitis.  The  operation  was  followed  by 
a  moderate  febrile  movement  (100^  to  101°),  and  after  three  days  by 
the  appearance  of  an  efflorescence,  with  sore  throat  and  the  strawberry 
tongue.  The  osteotomy  had  been  performed  under  carbolic  acid  spray 
and  with  all  the  details  of  antiseptic  surgery.  The  rash  soon  faded, 
the  temperature  fell,  and  the  child,  temporarily  separated  from  the 
other  patients  from  the  suspicion  that  the  disease  was  scarlet  fever,  was 
brought  back  to  the  ward.  The  subsef[uent  history  confirmed  the 
diagnosis  of  scarlet  fever,  for  the  skin  desquamated,  and  on  April  1st 
abundant  albumen  was  found  in  the  urine.  The  case  terminated  favor- 
ably. Three  months  previously  the  same  operation  had  been  performed 
on  the  other  leg,  with  no  unfavorable  symptoms.  On  April  otli,  three 
weeks  after  tlie  osteotomy,  a  lipoma  was  removed  from  another  patient 
aged  twenty-one  years.  The  following  day  tlie  temperature  rose  to 
101°,  and  remained  at  that  till  April  8th,  when  it  suddeidy  increased 
to  100°,  and  a  rose-rash  occurred  over  the  body,  with  sore  tliroat.  On 
April  9th,  Ilowse  excised  the  elbow-joint  of  a  girl  of  sixteen  years 
having  jtulpy  disease.  On  the  10th  her  tem|)crature  began  to  increase, 
and  on  the  11th  reached  105.8°.  Toward  evening  a  roseoloid  eruption 
appeared  over  her  body,  and  she  was  isolated.  On  April  12tli,  Dr.  II. 
excised  a  fibroid  bursa  patellaj  from  a  woman  of  twenty-nine  years. 
On  the  following  day  her  temperature  was  99°,  but  on  the  14th  it  rose 
to  100°,  and  on  the  evening  of  the  15th  .she  had  rigors  and  headache. 
On  the  morning  of  the  10th  the  temperature  was  102.5°,  and  a  roseo- 


206  SCARLET    FEVER. 

loid  eruption  occurred  over  the  face  and  chest.  The  surgeons  now  per- 
ceived that  an  epidemic  of  the  so-called  surgical  scarlatina  was  occurring, 
so  as  to  justify  the  postponement  of  other  operations. 

In  the  same  volume  of  Guij's  Hospital  Reports,  James  F.  Goodhart 
gives  the  histories  of  nearly  thirty  cases  of  this  disease  occurring  during 
a  series  of  years  in  the  same  hospital.  The  patients  Avere  chiefly  chil- 
dren, having  the  most  diverse  surgical  ailments,  among  which  may  be 
mentioned  hip  disease  and  abscess,  genu  valgum  without  operation, 
necrosis  of  femur,  hydrocele  with  explorative  operation,  a  scald,  a  sinus 
over  the  great  trochanter,  spinal  disease  with  abscess,  tenotomy  for  club- 
foot, and  vesical  calculus  with  operation.  The  most  common  disease 
was  caries  or  necrosis  with  abscess.  In  cases  operated  on  the  intervals 
between  the  operations  and  the  occurrence  of  the  efflorescence  varied 
from  two  days  to  more  than  two  weeks.  Goodhart,  after  a  careful 
examination  of  these  cases,  came  to  the  conclusion  that  they  were  for 
the  most  part  examples  of  true  scarlet  fever,  especially  as  a  considerable 
proportion  of  them  occurred  in  groups,  and  there  was  a  known  exposure 
of  some  of  the  patients  to  children  admitted  into  the  hospital  with  the 
sequelae  of  scarlet  fever. 

In  the  British  Med.  Journ.  for  Jan.  1879,  George  May,  Jr.,  reported 
a  case  of  efflorescence  in  surgical  practice  which  appears  to  have  been 
scarlatinous.  A  child  was  operated  on  for  the  radical  cure  of  hernia 
on  Dec.  4th.  Toward  the  close  of  the  same  day  he  became  restless, 
vomited,  and  his  pulse  on  the  following  day  rose  to  136.  Forty-eight 
hours  after  the  operation  a  rash  appeared  on  the  chest  and  arms,  the 
abdomen  became  tense  and  painful,  and  on  the  following  day  he  died. 
The  poison,  however,  in  this  case  may  have  been  septic. 

Hillier  remarks  {Diseases  of  Children):  "In  the  hospital  for  sick 
children,  of  the  children  who  contract  scarlatina  a  very  large  proportion 
have  been  the  subjects  of  a  surgical  operation  Avithin  a  week  before  the 
rash  appears."  Gee  says  (Reynolds's  System  of  Medicine):  "It  has 
been  doubted  by  some  whether  the  scarlatiniform  rash  Avhich  sometimes 
follows  operations  is  really  scarlatinal.  The  eruption  appears  from  the 
second  to  the  sixth  day  after  the  operation,  and  in  the  cases  which  have 
caused  the  doubt  is  very  fugitive  and  the  first  and  only  symptom.  Yet 
that  the  disease  really  is  scarlet  fever  would  seem  to  be  proved  by  the 
following  observations :  first,  that  the  disease  occurs  in  epidemics ; 
secondly,  that  in  a  given  epidemic  a  severe  case  occasionally  relieves 
the  monotonous  recurrence  of  the  very  mild  form  ;  thirdly,  that  a  pre- 
cisely similar  scarlatinilla  attacks  in  the  same  epidemic  patients  who 
have  not  been  subjected  to  operation  and  who  have  no  open  sore;  and 
lastly,  by  way  of  a  veritable  experimentum  crucis,  that,  however  freely 
these  patients  are  exposed  to  ordinary  scarlet  fever  contagion,  after- 
ward, they  do  not  contract  that  disease."  Paget  and  other  distinguished 
London  surgeons  who  have  observed  this  complication  of  surgical  cases, 
believe  that  the  patients  have  been  previously  exposed  to  the  scarla- 
tinous poison,  and  that  the  surgical  diseases  or  operations  furnish  favor- 
able conditions  for  the  occurrence  of  scarlet  fever,  so  that  the  exposure, 
which  probably  would  have  been  without  result  in  ordinary  health, 
causes  an  outbreak  of  the  malady. 


SURGICAL    AND    OBSTETRICAL    SCARLATINA.  207 

Those  who  have  reported  cases  of  this  form  of  efflorescence  have  for 
the  most  part  neglected  to  state  whether  the  patients  had  had  scarlet 
fever  previously,  knowledge  of  which  Avould  have  aided  in  the  diagnosis; 
but  from  an  examination  of  the  histories  of  cases,  especially  those  pub- 
lished in  the  London  journals  in  the  last  four  or  ffve  years,  there  can,  I 
think,  be  little  doubt  that  surgical  maladies  of  a  certain  kind,  especially 
traumatism,  do  produce  a  state  of  system  which  predisposes  to  scarlet 
fever,  so  that  this  class  of  patients  are  especially  liable  to  contract  it. 
Therefore,  in  my  opinion,  a  considerable  proportion  of  reported  cases 
of  surgical  scarlatina  are  genuine,  but  in  a  considerable  number,  perhaps 
an  equal  number  of  such  cases,  the  histories  and  symptoms  indicated  a 
septic  rather  than  scarlatinous  efflorescence,  and  in  not  a  few  instances, 
when  consultations  have- been  held,  opinions  differed,  some  diagnosti- 
cating scarlet  fever,  others  septicaemia.  In  some  of  the  cases  I  find  it 
stated  that  the  fauces  presented  the  normal  appearance.  Now,  faucial 
redness  is  so  generally  present  in  scarlet  fever,  antedating  that  of  the 
skin  and  coexisting  with  it,  that  its  absence  is  strong  evidence  that  the 
disease  is  not  scarlatinous.  Moreover,  when,'  as  was  true  of  certain  of 
the  reported  cases,  the  rash  appeared  irregularly  upon  the  surfice,  and 
faded  away  in  two  or  three  days  with  the  abatement  of  the  fever,  and 
the  conditions  for  septic  absorption  were  present,  the  efflorescence  was 
probably  septic?emia. 

The  following  were  apparenth'^  cases  of  septicaemic  efflorescence :  A 
child  aged  five  years,  (Brit.  3Ied.  Joiirn.,  Feb.  15, 1879)  had  inflammation 
of  the  lymphatic  glands  in  the  groin,  which  suppurated.  At  the  time 
when  the  abscess  was  fully  formed  a  rash  appeared  over  the  entire  body. 
It  consisted  of  numerous  red  points,  but  was  paler  than  that  of  ordinary 
scarlet  fever;  temperature  never  above  99°;  no  sore  throat  nor  desqua- 
mation of  cuticle  Xo  child  exposed  to  her  took  scarlet  fever,  and  her 
sickness  could  not  be  traced  to  infection.  In  the  British  3Ied.  Journ., 
Jan.  4,  1879,  L.  Braxton  Kicks  states  that  his  son,  attending  school 
at  Reading,  was  seized  with  a  severe  attack  of  pyrexia,  accompanied  on 
the  second  day  by  delirium  and  the  occurrence  of  a  rash  like  scarlet  fever 
over  the  entire  surface.  He  had  no  decided  redness  of  the  fiiuces,  though 
it  was  perha])S  slightly  flushed.  The  right  buttock  was  swollen  from 
inflammation,  and  a  large,  deep-seated  abscess  formed  near  the  tuberosity 
of  the  ischium.  AVhen  the  delirium  abated  the  boy  said  tliat  he  was 
standing  the  day  before  the  fever  began  with  his  legs  far  apart,  when  a 
schoolfellow  stretched  them  further  by  suddenly  pulling  on  one  of  them. 
The  rash,  which  was  nearly  universal,  lasted  three  days,  and  was  not 
followed  by  desquamation.  No  case  of  scarlet  fever  occurred  in  the 
school  before  or  afterward.  In  the  same  volume  of  the  British  Medical 
Journal,  burgeon  Frolliott,  of  tlie  East  India  Service,  relates  the  case  of  a 
jjrivate,  aged  twenty-three  years,  and  three  years  in  India,  who,  when  on 
duty  in  the  Punjab,  was  injured  by  the  explosion  of  an  Afghan  powder- 
magazine.  The  accident  occurred  Dec.  21, 1878.  On  Dec.  '2r)th  a  bright 
scarlet  rash  appeared  upon  the  abdomen  antl  spread  over  the  entire  body. 
The  following  day  the  eruption  was  very  vivid,  like  a  boiled  lobster,  and 
it  lasted  five  days.  The  temperature,  Avhicli  in  the  beginning  had  been 
101°,  abated  to  the  normal  after  the  rash  appeared.     No  soreness  of 


208  SCARLET    FEVER. 

throat  nor  redness  of  the  buccal  surface  occurred,  but  the  epidermis 
desquamated  even  from  the  pahiis  of  the  hands  and  soles  of  the  feet. 
Now,  the  febrile  movement  of  scarlet  fever  does  not  cease  while  the 
efflorescence  is  distinct.  It  does  not  even  dimmish  when  the  eruption 
appears,  Avhile  in  the  above  case  it  fell  to  the  normal — a  common  occur- 
rence in  septicemia,  even  when  the  blood-poisoning  is  profound.  More- 
over, scarlet  fever  is  so  rare  in  India  that  FroUiott,  after  twelve  years' 
service,  had  only  heard  of  one  case  among  Europeans  and  natives.  The 
surgeons  who  consulted  over  the  case  of  this  private  disagreed  in  opinion, 
some  regarding  tlie  disease  as  septici^mic,  others  as  scarlatinous.  But  a 
better  knowledge  of  the  clinical  history  of  scarlet  fever  on  the  ^mrt  of 
these  army  surgeons  would,  I  think,  have  removed  all  doubt  as  to  the 
diagnosis. 

It  is  the  opinion  of  some  reputable  surgeons  that  the  exposure  of 
traumatic  patients  to  the  scarlatinous  poison  sometimes  aggravates  the 
inflammation  of  wounds,  causing  them  to  assume  an  unhealthy  appear- 
ance even  though  no  scarlatina  be  produced.  The  late  Dr.  Solly  made 
the  remark,  "^Vhenever  a  case  of  surgery  in  private  practice  takes  on  a 
highly  phlegmonous  appearance  I  am  always  sure  to  find  break  out,  in 
the  inmates  of  the  house,  either  erysipelas  or  scarlet  fever  "  {British  Med. 
Journ.^  Feb.  15,  1879).  We  will  see  that  the  scarlatinous  poison  some- 
times causes  pharyngitis  or  nephritis  Avithout  producing  the  general  dis- 
ease. In  a  similar  manner  it  seems  that  it  may  aggravate  open  wounds, 
intensifying  the  inflammation  in  them,  while  there  is  no  efflorescence  or 
other  symptom  to  show  that  scarlatina  itself  is  present.  The  poison 
appears  to  act  entirely  locally  in  such  cases. 

Paget,  in  his  Clinical  Lectures,  says :  "  I  think  it  not  improbable 
that  in  some  cases  results  occurring  with  obscure  symptoms  within 
two  or  three  days  after  operations  have  been  due  to  the  scarlet-fever 
poison,  hindered  in  some  way  from  its  usual  progress."  Playfair, 
in  his  remarks  on  the  puerperal  state,  adds :  "  Mr.  Spencer  Wells  in- 
forms me  that  he  has  seen  cases  of  surgical  pyremia  which  he  had  reason 
to  believe  originated  in  the  scarlatinal  poison ;  and  his  well-known  suc- 
cess as  an  ovariotomist  is  no  doubt,  in  a  great  measure,  to  be  attributed  to 
his  extreme  care  in  seeing  that  no  one  likely  to  come  in  contact  with  his 
patients  has  been  exposed  to  any  such  source  of  infection."  Opinions 
like  these,  held  by  such  prominent  members  of  the  profession  and  sus- 
tained by  many  observations,  should  certainly  induce  physicians  to  pre- 
vent, so  far  as  possible,  exposure  of  their  surgical  patients,  especially  if 
they  have  sores  or  wounds,  whether  by  traumatism  or  scalpel,  to  the 
scarlatinal  poison. 

Obstetrical  Scarlatina. — Women  during  convalescence  after  child- 
birth are  very  liable  to  contract  scarlet  fever.  In  the  New  York  Infant 
Asylum,  which  has  maternity  wards,  a  woman  was  admitted  from  a 
house  in  Avhich  scarlet  fever  was  prevailing,  and  assigned  to  a  cot  next 
that  occupied  by  one  of  the  waiting  women,' who  was  confined  soon  after- 
ward, ller  labor  was  favorable,  but  three  days  afterward  she  took 
scarlet  fever,  and  another  lying-in  patient  contracted  it  from  her.  The 
sore  throat  and  desquamation  were  characteristic.  It  has  come  to  my 
knowledge  that  a  physician  of  New  York,  in  whose  family  scarlet  fever 


OBSTETRICAL    SCARLATINA,  208 

Tvas  occurring,  attended  three  women  in  succession  in  their  confinement, 
and  all  contracted  scarlet  fever,  Avhich  presented  the  characteristic  symp- 
toms, and  two  of  them  died.  Experienced  and  cautious  physicians  of 
New  York,  aware  of  the  danger,  do  not  go  directly  from  a  scarlatinous 
patient  to  an  obstetrical  case,  but  avoid  the  risk  by  intermediate  visits  to 
other  patients  or  by  remaining  for  a  time  in  the  open  air. 

Playfair,  remarking  on  this  subject,  says :  "  There  is  good  reason  to 
believe  that  the  contagium  of  zymotic  diseases  may  produce  a  form  of 
disease  indistinguishable  from  ordinary  puerperal  septicaemia,  and  pre- 
senting none  of  the  characteristic  features  of  the  specific  complaint  from 
which  the  contagium  was  derived.  This  is  admitted  to  be  a  fact  by  the 
ma.jority  of  our  most  eminent  British  obstetricians,  although  it  does  not 
seem  to  be  allowed  by  Continental  authorities,  and  it  is  strongly  contro- 
verted by  some  writers  in  this  country.  It  is  certainly  difficult  to  recon- 
cile this  with  the  theory  of  septicaemia,  and  we  are  not  in  a  position  tc 
give  a  satisfactory  explanation  of  it.  I  believe,  however,  that  the  evi- 
dence in  favor  of  the  possibility  of  puerperal  septicaemia  originating  in 
this  way  is  too  strong  to  be  assailable.  The  scarlatinal  poison  is  that 
regarding  which  the  greatest  number  of  observations  has  been  made. 
Numerous  cases  of  this  kind  are  to  be  found  scattered  through  our 
obstetric  literature,  but  the  largest  number  are  to  be  met  with  in 
a  paper  by  Braxton  Ilicks.  Out  of  QS  cases  of  puerperal  disease 
seen  in  consultation,  no  less  than  37  were  distinctly  traceable  to  the 
scarlatinal  poison.  Of  these,  20  had  the  characteristic  rash  of  the 
disease,  but  the  remaining  17,  although  the  history  clearly  proved 
expo.sure  to  the  contagium  of  scarlet  fever,  showed  none  of  its  usual 
symptoms,  and  were  not  to  be  distinguished  from  ordinary  typical  cases 
of  the  so-called  ])uerperal  fever.  On  the  theory  that  it  is  impossible 
for  the  specific  contagious  diseases  to  be  modified  by  the  puerperal  state, 
we  have  to  admit  that  one  physician  met  with  17  cases  of  puerperal 
septicaemia  in  which,  by  a  mere  coincidence,  the  contagion  of  scarlet 
fever  had  been  traced,  and  that  the  disease  nevertheless  originated  from 
some  other  source — a  hypothesis  so  improbable  that  its  mere  mention 
carries  its  own  refutation." 

Parturition,  like  traumatism,  furnishes  in  an  eminent  degree  the  con- 
ditions in  which  septic  poisoning  occurs,  and  the  efflorescence  which 
often  accompanies  septicaemia  bears,  as  we  have  seen,  a  very  close  re- 
semblance to  that  of  scarlet  fever.  Hence  in  many  instances  the  same 
difficidty  is  present  in  making  a  differential  diagnosis  between  septic 
and  scarlatinous  blood-poisf)ning  in  oljstetrical  cases  which  occurs  in 
surgical  practice.  But,  according  to  my  observations,  an  efflorescence 
occurring  during  the  week  following  parturition  is  in  most  instances 
septic.  It  is  only  in  exceptional  cases  that  it  is  scarlatinous,  and  there 
is  little  danger  that  the  accoucheur,  engaged  in  general  practice  and 
visiting  scarlatinous  patients,  will  communicate  scarlet  fever  through 
his  person  or  clothing  if  lie  exercise  proper  precautions.  His  short 
stay  in  the  sick-room  and  his  outdoor  exercise  in  visiting  cases  prevent 
infection  of  his  person  or  dress.  But  if,  as  Playfair  believes,  the  scar- 
latinal poison  sometimes  produces  in  parturient  women  a  puerperal 
fever  in  which  the  characteristic  scarlatinal  symptoms  are  lacking,  and 

14 


210  SCARLET    FEVER. 

which,  in  the  present  state  of  our  knowledge,  is  not  distinguishable 
from  ordinary  septic  fever,  certainly  the  scarlatinous  virus  sustains  a 
much  more  frequent  causative  relation  to  childbed  fever  than  has  been 
heretofore  supposed. 

Infants  under  the  age  of  six  months  do  not  ordinarily  contract 
scarlet  fever,  although  fully  exposed,  and  those  under  four  months 
nearly  possess  immunity.  Still,  this  disease  has  been  observed  in  new- 
born infants,  contracted  apparently,  through  the  placental  circulation. 
Tourtual  states  that  a  woman  waited  upon  her  own  husband  and  child, 
both  of  whom  had  scarlet  fever,  during  the  eio-hth  and  ninth  months  of 
her  pregnancy,  till  near  her  confinement.  Though  she  had  no  symp- 
toms of  scarlet  fever,  her  infant  had  unusual  redness  of  the  skin  and 
buccal  surface  and  difficulty  of  swallowing  up  to  the  fifth  day.  On  the 
ninth  day  desquamation  began,  and  at  a  later  stage  the  nails  of  the 
fingers  and  toes  separated.  A  case  having  a  history  in  some  respects 
similar  is  related  by  Megnert,  but  the  symptoms  were  anomalous  for 
scarlet  fever,  and  the  disease  may  have  been  ordinar}'.  septic  fever.  On 
the  other  hand,  in  one  instance  in  my  practice  a  mother  had  scarlet 
fever,  beginning  about  the  third  day  after  her  confinement,  and  although 
she  suckled  her  infant  and  it  was  constantly  in  bed  Avith  her,  it  had  no 
symptoms  of  scarlet  fever,  although  it  became  aff'ected  immediately  after- 
ward by  a  severe  form  of  eczema,  probably  from  the  altered  quality  of 
the  milk  ;  and  in  two  instances  observed  by  JNIurchison  new-born  infants 
remained  healthy,  although  their  mothers  suffered  from  scarlet  fever. 

After  the  age  of  six  months  the  liability  to  scarlet  fever  increases  till 
the  close  of  infancy,  children  between  the  ages  of  six  months  and  one 
year  being  less  liable  to  contract  the  malady  than  during  the  second 
year,  and  those  in  the  second  A^ear  being  less  liable  to  it  than  those  in 
the  third  year.  Murchison  collected  the  statistics  of  deaths  from  scarlet 
fever  in  England  and  Wales  during  a  series  of  years  ending  with  1861. 
The  number  of  deaths  aggregated  148,829,  and  the  percentage  of  deaths 
at  different  ages  was  as  follows : 

Deaths    under     1  year .67    per  cent. 

"       between   1  and    2  j'ears  .....  14.09  " 

"  "          2  and    3      " 16  00  " 

"  "         3  and    4      " 15.13  " 

"  "         4  and    5      « 11.9  " 

««  "          5  and  10      " 25.9  " 

««  "        10  and  15      " 5.8  " 

»  "        15  and  25      " 2.6  " 

"  "       25  and  35      " 0  8  " 

«'  over   age   of    35     " 0.8  " 

Among  the  deaths  were  ten  cases  above  the  age  of  eighty-five  years,  so 
that  scarlet  fever,  though  especially  a  disease  of  childhood,  may  occur 
in  any  decade  of  life ;  but  old  age,  like  early  infancy,  almost  possesses 
immunity  from  it. 

I  have  preserved  the  records  of  the  ages  of  145  consecutive  cases 
occurring  in  private  practice.  If  we  add  to  these  58  cases  observed  by 
Prof.  Octerlony  {Amer.  Jour,  of  Med.  Sci.,  July,  1882)  we  have  the 
statistics  of  the  ages  of  203  cases,  which  are  embraced  in  the  following 
table : 


CLINICAL    FACTS    REGARDING    SCARLET    FEVER.       211 

Under    1  year      ..........  3 

From  1  to    2  years 25 

"  2  to    3  '  " 43 

"  3  to    5     " 57 

"  5  to  10     " 53 

"  10  to  15     " 13 

"  15  to  20     " 3 

"  20  to  30      " 4 

"  30  to  40     " 2 

Total .203 

Clinical  Facts  regarding  Scarlet  Fever. — As  a  rule,  scarlet 
fever  occurs  but  once,  one  attack  conferring  immunity  from  the  disease 
for  life;  but  there  are  exceptions.  In  1869,  I  attended  a  child  with 
fatal  scarlet  fever  who  three  years  previously,  it  was  stated,  had  passed 
through  a  first  attack  with  all  the  characteristic  symptoms.  The  fol- 
lowing case  occurred  in  a  family   attended  by  the  late   Dr.   Herzog : 

R ,  a  boy  of  six  years,  had  scarlet  fever  in  a  mild  form  in  January 

and  February,  1875,  followed  by  moderate  desquamation.  In  July  of 
the  same  year  he  was  kicked  by  a  horse  in  the  street,  receiving  a  deep 
scalp-wound  Avhich  required  three  stitches.  Three  days  afterward  he 
had,  to  appearance,  a  second  attack  of  scarlet  fever,  attended  by  high 
febrile  movement,  and  followed  also  by  desquamation.  It  was  believed 
by  Dr.  H.  to  be  a  genuine  case,  and  was  so  treated.  I  am  not  able  to 
state  as  regards  the  presence  of  soreness  of  the  throat,  and  doubt  arises 
whether  this  second  attack  may  not  have  been  septicsemic.  In  April, 
1876,  a  third  attack  occurred,  which  I  saw  from  the  beginning.  It  was 
accompanied  by  all  the  characteristic  symptoms — injection  of  the  fauces, 
an  efflorescence  continuing  the  usual  time,  followed  by  desquamation 
and  albuminuria,  the  latter  remaining  several  weeks.  Richardson 
states  that  three  distinct  attacks  occurred  in  his  own  person,  and  a 
student  attending  the  lecture  at  which  this  was  mentioned  informe<l  the 
doctor  that  he  also  had  had  scarlet  fever  three  times. 

Sometimes  a  second  attack  occurs  .so  soon  after  the  first  that  it  has 
been  described  as  a  relapse.  The  following  was  a  case  in  point  in  the 
practice  of  Godneff  {Meditz.  Vestnik.,  No.  iv.,  N.  Y.  Med.  Rec, 
April  30,  1881"):  A  youth  of  seventeen  years  contracted  scarlet  fever 
while  taking  care  of  a  child.  It  began  with  a  chill,  and  he  had  the 
usual  efflorescence,  sore  throat,  and  tumefaction  of  the  cervical  glands. 
An  exudation  appeared  upon  his  tonsils  and  uvula,  and  his  temperature 
reached  104°.  The  urine  contained  a  trace  of  albumen,  the  rash  in  due 
time  faded,  and  the  epidermis  exfoliated.  On  the  fifteenth  day,  when 
he  was  about  ready  to  leave  the  hospital,  he  again  had  a  chill,  followed 
by  fever.  The  temperature  reached  10'). 2°,  the  ra.sh  reappeared  over 
the  entire  surfiice  except  the  face,  diphtherific  exudations  occurred  upon 
the  fauces,  an<l  the  urine,  tiie  quantity  of  wjiich  was  diminished,  again 
became  albuminous.  This  second  efflorescence  faded  on  the  twenty- 
fourth  day,  and  on  the  twenty-seventh  exfoliation  began.  Ilillicr  says: 
"  I  have  seen  a  young  woman  in  the  fever  hospital  suffering  from  a  second 
attack  of  scarlatina,  the  fir.^t  attack  having  occurred  five  weeks  pre- 
viously. She  had  quite  recovered  from  her  first  illness,  and  was  acting 
as  nurse.     In  both  seizures  the  rash,  the  sore  throat,  and  other  symp- 


212  SCARLET    FEVER. 

toms  were  characteristic.  The  relapse  or  recurrence  was  less  severe 
than  the  primary  disease."  Cases  of  a  fourth,  or  even  of  a  greater 
number  of  attacks,  have  been  reported.  The  first  seizure  is  sometimes 
milder,  but  in  other  instances  is  more  severe,  than  those  which  follow. 

Exposure  to  the  scarlatinous  poison  not  infrequently  produces  pharyn- 
gitis without  the  occurrence  of  scarlatina,  and  the  inflammation  is  usually 
severe,  accompanied  by  pain  in  swallowing  and  marked  febrile  move- 
ment. This  phlegmasia  is  distinguished  from  scarlet  fever  by  its  shorter 
duration  and  the  absence  of  the  efliorescence.  It  occurs  in  adults  as 
well  as  in  children,  and  in  those  who  have  had,  as  Avell  as  in  those  who 
have  not  had  scarlatina.  So  far  as  I  have  observed,  it  is  very  seldom 
accompanied  or  followed  by  any  of  the  complications  or  sequelae  so  com- 
mon in  and  after  scarlet  fever.  It  cannot  be  distinguished  from  ordinary 
pharyngitis  except  in  the  manner  in  which  it  occurs,  and  one  attack 
does  not  preclude  another.  The  late  George  B.  Wood  made  the  remark 
that  he  never  attended  a  case  of  scarlet  fever  without  suffering  fiom 
sore  throat.  The  following  were  examples  of  this  form  of  pharyngitis: 
On  Jan.  17,  1882,  I  was  called  to  a  boy  of  three  years  with  severe 
scarlet  fever,  ushered  in  by  convulsions.  On  the  following  day  his  sis- 
ter, aged  seven  and  three-fourths  years,  whom  I  had  attended  a  year 
pi'eviously  during  a  severe  attack  of  scarlatina,  and  who  had  been  almost 
constantly  with  the  brother,  became  very  ill,  Avith  a  temperature  of 
103.5°.  Examination  revealed  severe  inflammation  of  the  fauces,  with- 
out pseudo-membrane  or  any  other  exudation  except  muco-pus.  On 
Jan.  10th  an  older  brother,  nine  years,  whom  I  had  attended  in  scarlet 
fever  three  years  previously,  was  aftected  in  the  same  way,  his  temper- 
ature being  104°  and  his  respiration  guttural  and  noisy,  especially 
during  sleep,  in  consequence  of  the  great  amount  of  faucial  swelling. 
At  times  he  was  delirious.  The  inflammation  in  both  cases  began  to 
abate  about  the  third  day,  and  had  disappeared  by  the  close  of  the  week. 
That  the  contagium  of  scarlet  fever  may  be  received  into  the  system  and 
cause  pharyngitis,  while  the  patient  has  immunity  from  scarlet  fever 
through  a  previous  attack,  and  that  this  inflammation  may  occur  any 
number  of  times,  as  in  the  case  of  Dr.  Wood,  are  remarkable  facts. 

Now  and  then  cases  occur  which  appear  to  show  that  the  scarlatinous 
poison  may  affect  the  kidneys,  producing  nephritis,  while  there  is  no 
other  manifestation  of  its  influence.  Thus  in  my  practice  a  lady  of 
about  forty-five  years  constantly  attended  her  son,  sleeping  by  his  side, 
during  an  attack  of  scarlet  fever.  Her  health  had  previously  been  good. 
When  the  boy  was  convalescent,  as  her  appetite  failed  and  she  was  in- 
disposed, a  careful  examination  revealed  the  fact  that  she  had  albumin- 
uria, although  she  had  had  no  sore  throat  or  other  symptoms  of  scarlet 
fever.  After  several  weeks  of  treatment  her  disease  was  removed,  and 
she  has  remained  well  since.  In  the  British  Med.  Jour,  for  Nov.  29, 
1879,  it  is  stated  that  in  a  family  four  girls  were  found  to  be  suffering 
from  desquamative  nephritis.  One  of  them  had  recently  had  scarlet 
fever,  but  the  other  three  had  presented  no  symptoms  whatever  of  this 
disease.  Such  cases,  although  probably  rare,  appear  to  show  that,  as 
the  scarlatinous  poison  may  produce  inflammation  of  the  fauces  without 
the  occurrence  of  scarlet  fever,  so  it  may  cause  nephritis  without  pro- 


SYMPTOMS.  213 

ducing  the  general  disease,  or  apparently  disturbing  the  functions,  or 
changing  the  state  of  other  parts,  except  the  kidneys. 

Symptoms. — Ordinary  Form.  Scarlet  fever  usually  begins  abruptly, 
so  that  the  exact  time  of  its  commencement  can  be  fixed.  If  any  pre- 
monitory symptoms  occur,  they  are  slight,  so  as  scarcely  to  attract  atten- 
tion, as  languor  or  the  appearance  of  fatigue.  A  dusky  aspect  of  the 
surface  may  occasionally  be  observed  during  the  few  hours  preceding 
the  attack.  In  some  children  the  first  symptom  is  chilliness,  and  oc- 
casionally a  distinct  chill  occurs.  In  the  adult  a  chill  is  ordinarily  the 
first  symptom.  With  or  without  the  initial  chilliness,  febrile  movement 
occurs,  of  variable  intensity  according  to  the  seventy  of  the  type,  and 
accompanied  by  such  symptoms  as  usually  arise  in  a  febrile  state  of 
system,  as  cephalalgia,  anorexia,  and  thirst.  The  pulse  rises  to  HO, 
120,  or  more  per  minute,  the  temperature  to  1Q2°  J03°,  or_104° ;  the 
skin  is  hot,  face  flushed,  and  the  eyes  bright.  Even  in  cases  that  are 
not  malignant  or  grave,  and  that  give  indications  of  a  favorable  result, 
there  is  often  more  or  less  stupor,  with  transient  delirium  and  sudden 
starting  or  twitching  of  the  extremities,  showing  that  the  cerebro-spinal 
axis  is  involved. 

Vomiting  is  a  common  symptom  in  the  beginning  of  scarlet  fever, 
occurring  Ijefore  the  appearance  of  the  efllorescence.  It  therefore  has 
diagnostic  value  when  the  nature  of  the  case  is  still  doubtful.  In  some 
patients  it  is  an  initial  symptom,  but  in  others  some  hours  liave  elapsed 
when  it  occurs.  I  recorded  its  presence  or  absence  in  214  patients,  with 
the  following  result:  present  in  162  patients,  absent  in  52.  In  severe 
forms  of  the  disease  it  is  rarely  absent,  and  if  it  do  not  occur  it  is  probable 
that  the  case  will  be  mild,  requiring  little  treatment,  and  having  a  favor- 
able termination.  In  epidemics  of  unusual  mildness  the  number  of  cases 
without  vomiting  may  be  in  excess  of  those  in  which  this  symptom 
occurs.  It  appears  to  be  due  to  functional  disturbance  of  the  cerebro- 
spinal system,  and  may  therefore  be  properly  regarded  as  a  nervous 
symptom.  In  severe  cases  the  vomiting  is  a])t  to  be  repeated,  not  only 
on  the  first  but  on  subsequent  days,  and  we  shall  see  that  in  cases  of  great 
gravity,  in  which  a  fatal  termination  is  not  improbable,  persistent  vomit- 
ing, by  which  the  food  and  stimulants  so  urgently  required  are  rejected, 
interferes  seriously  with  successful  treatment.  In  a  few  cases  embraced 
in  my  statistics  nausea  without  vomiting  was  recorded.  The  bowels  in 
ordinary  scarlatina  act  regularly  or  are  slightly  constipated.  Diarrhoea, 
which  so  commonly  accom))anies  the  persistent  vomiting  in  malignant 
cases,  if  it  occur  in  this  form  of  the  malady  is  slight  and  transient  and 
due  to  accidental  causes.  The  food,  if  it  be  given  in  the  liquid  fonn  and 
cool,  is  usually  taken  readily,  on  account  of  the  thirst,  excejjt  when 
deglutition  is  rendered  painful  by  the  pharyngitis. 

The  sym|)toms  pertaining  to  the  nervous  system  vary  according  to  the 
severity  of  the  disease  and  the  temperament  of  the  patient.  Many 
children  during  the  progress  of  the  common  form  of  scarlet  fever 
present  a  dull  or  apathetic  appearance.  'I'hey  lie  much  of  the  time 
with  their  eyes  closed;  others  are  more  restless,  and  not  a  few,  if  the 
fever  be  cfmsiderable,  have  occasional  twitchings  of  the  limbs  and  more 
or  less  headache.     Eclampsia  sometimes  occurs  on  the  first  day,  es2)ecial]y 


214  SCARLET    FEVER. 

in  those  predisposed  to  it,  even  when  the  subsequent  course  of  the  dis- 
ease is  mild  and  favorable.  This  complication,  very  grave  and  usually 
fatal  when  it  occurs  at  a  later  stage,  is  in  most  instances,  when  it  takes 
place  on  the  first  day,  readily  controlled  by  proper  remedies  and  with 
little  detriment  to  tlie  patient.  But  if  it  be  attended  by  high  elevation 
of  temperature  and  marked  drowsiness,  approaching  the  comatose  state, 
it  is  very  serious  upon  the  first  as  well  as  upon  subsequent  days.  Nervous 
sjnmtoms  occurring  in  the  beginning  of  scarlet  fever,  when  it  has  the 
ommary  favorable  type,  begin  to  abate  in  three  jar.  fourjiays,  but  if  tliey 
supervene  at  a  later  date,  and  especially  in  the  declining  stage,  they  j)0ssess 
more  gravity,  since~tKey  then  not  infre({uontly  result  from  and  indicate 
renal  complication. 

Early  in  tTTe  disease,  nearly  as  soon  as  the  commencement  of  the  fever, 
the  fancial  and  biiccal  surfaces  become  infljimed,  as  shown  by  redness, 
swelling,  and  tenderness.  The  physician  summoned  in  the  beginning 
of  an  attack  will  already,  at  his  first  visit,  observe  hyperaemia  of  the 
fauces,  with  points  of  deeper  injection  than  over  the  general  faucial 
surface,  and  soon  the  buccal  surface  also  participates.  The  inllamma- 
tion  at  first  produces  preternatural  dryness,  and  this  is  followed  by  a 
viscid  secretion.  The  papijlse  of  the  tongue  enlarge  and  become  promi- 
_nent,  giving  rise  to  the  appearance  known  as  straAyberry  tongue  which 
is  so  common  in  scarlet  fever.  This  state  of  the  buccal  and  faucial 
membrane  continues  throughout  the  disease.  A  thin  fui-  appears  upon 
the  tongue  on  the  first  day,  and  it  increases  on  the  second  and  third 
days,  after  which  it  is  usually  detached,  exposing  the  surface  of  the 
organ,  which  has  a  deep  red  hue,  but  in  not  a  few  patients  the  fur 
remains  or  is  reproduced  as  soon  as  shed.  Except  in  the  mildest  cases 
the  Schneiderian  membrane  also  participates  in  the  inflammation  as  the 
disease  advances,  so  that  a  thin,  irritating  discharge  containing  leu- 
cocytes or  pus-cells,  flows  from  the  nostrils.  The  skin  is  hot  and  dry, 
and  cutaneous  transpiration  nearly  checked.  The  respiratory  system 
is  rarely  involved  in  any  notable  manner  unless  there  be  a  compli- 
cation. Many  have  no  cough  whatever,  while  others  have  a  slight 
cough,  due  to  the  flict  that  the  inflammation,  of  a  catarrhal  form,  has 
extended  from  the  fiiuces  to  the  surflice  of  the  glottis.  Slight  accelera- 
tion of  respiration,  corresponding  with  the  degree  of  fever,  may  also  be 
observed.  The  Iddneys  commonly  act  reguhirly  and  normally  during 
the  first  days,  any  serious  impairment  of  their  functions  being  rare 
before  the  close  of  the  first  week. 

When  the  symj)toms  described  above  have  continued  from  six  to 
eighteen  hours  the  efflorescence  appears.  It  is  first  observed  about  the 
ears,  neck,  and  shoulders,  in  reddish  patches  fSxding  into  the  normal 
hue.  These  patches  extend  and  unite,  and  in  the  course  of  a  few  hours 
the  trunk  and  upper  extremities,  and  finally  the  legs,  are  covered.  The 
scarlatinous  rash  usually,  when  fully  developed,  resembles  that  produced 
by  external  heat  or  the  apf)lication  of  a  sinapism.  It  has  been  likened 
to  the  appearance  of  a  boiled  lobster,  but  there  are  numerous  minute 
points  of  a  deeper  or  duskier  hue  than  the  surface  generally.  In  many 
patients  the  rash  appears,  especially  over  the  abdomen  and  lower  ex- 
tremities, as  minute,  thickly  set  points,  with  the  skin  of  normal  appear- 


SYMPTOMS.  215 

ance  between  them.  Henoch,  of  Berlin,  says  of  scarlet  fever :  "  In 
general,  the  moderate  grades  of  eruption  prevail,  the  skin,  when  seen 
from  a  distance,  presenting  a  diflfuse,  more  or  less  scarlet  redness,  while 
on  closer  inspection  it  is  found  that  this  redness  is  composed  of  innu- 
merable red  points  clo.sely  situated  together,  and  separated  from  one 
another  by  very  small  paler  portions  of  skin.  The  dark-red  points 
appear  to  correspond  to  the  hair  follicles."  On  passing  the  finger  over 
the  efflorescence  no  distinct  prominences  are  observed,  but  a  sensation 
of  roughness  is  sometimes  imparted  from  engorgement  of  the  cutaneous 
papillae.  The  rash  disappears  on  pressure,  but  it  immediately  reappears 
when  the  pressure  is  removed.  Its  slow  return  is  evidence  of  sluggish 
circulation,  and  it  indicates  a  grave  and  dangerous  form  of  the  malady. 
The  color  is  then  usually' a  dusky  instead  of  a  bright  red.  The  efflo- 
rescence is  most  marked  in  dependent  parts,  as  along  the  back,  over  the 
chest  and  abdomen,  and  in  the  flexures  of  the  joints.  Parts  pressed 
upon  by  the  bedclothes,  which  confine  and  intensify  the  heat,  present  a 
deeper  coloration  than  other  portions  of  the  surface.  Often,  especially 
in  mild  cases,  the  rash  is  absent  from  portions  of  the  surface  where  it 
commonly  appears,  while  it  presents  its  typical  character  elsewhere. 
Tardy  and  incomplete  establishment  of  the  rash  when  the  symptoms 
indicate  an  attack  of  ordinary  or  more  than  ordinary  severity  is  com- 
monly due  to  some  perturbating  cause,  es})ecially  diarrhoea.  In  the 
London  Lancet  for  Aug.  16,  1870,  cases  are  related  of  supposed 
scarlet  fever  without  the  rash,  cases  in  which  pharyngitis  and  stomatitis 
with  the  strawberry  tongue  occurred,  without  eiliorescence  upon  the 
skin  ;  but  it  is  to  be  remembered,  as  stated  above,  that  the  inflamma- 
tions which  commonly  attend  or  follow  scarlet  fever,  particularly  the 
pharyngitis  and  nei>hritis,  not  infrequently  occur  in  those  wlio  have 
already  had  scarlatina,  and  occur  more  than  once  from  fresh  exi)Osure 
to  scarlatiiui  patients.  These  inflammations,  occurring  under  such  cir- 
cumstances, appear  to  be  purely  local  maladies,  produced  by  the  scarla- 
tinous vi)-us ;  and  it  seems  to  me  a  question  whether,  in  the  so-called 
scarlatina  without  efflorescence,  the  inflammations  which  are  present, 
and  which  undoubtedly  have  a  T'Carlatinous  origin,  are  not  local  in  their 
nature,  instead  of  being  local  manifestations  of  the  constitutioiud  disease. 
Tiie  l<urniug  and  ik'.Uiii;;ji(jnstjji()n  ]»roduced  by  the  rash  increases  the 
restlessness  of  the  patient,  and  is  sometimes  the  most  annoying  of  the 
symptoms. 

The  temperature  in  the  common  favorable  forms  of  scarlet  fever 
usually  varies  from  101°  in  the  mildest  cases  to  108°  or  104°  in  those 
more  severe.  If  it  attain  Tjii°  <^'''  over,  the  case  is  jtroperly  (U-sigiiated 
gnavc  or  severe.  The  febrile  movement  ordinarily  fluctuates  but  little 
trom  day  to  day  till  tlie  fourth  or  fifthjlay,  when,  if  the  case  be  favor- 
able and  no  coiuplication  occur,  it  begins  to  decline.  The  temi)erature 
is  as  high  in  the  beginning  of  the  attack  as  subse([ucntly. 

The  synq)touis  pertaining  to  the  digestive  system  during  the  initial 
period  of  scarlet  fever  liaAc  been  sidficiently  descril)ed.  Tin,' stibse(|uent 
syni|)toms  referable  to  this  system  do  not  differ  materially  fioui  those 
])resent  in  the  l)eginning,  except  the  absence  of  vomiting.  Tlie  lips 
are  dry  and  often  cracked.     The  inflammation  of  the  mouth  and  throat 


216  SCARLET    FEVER. 

continues,  with  anorexia  and  thirst.  With  the  dedine  of  the  disease 
the  appetite  gradually  returns,  but  it  is  not  till  the  close  of  the  second 
week  that  it  is  fully  restored.  Great  and  continued  disturbance  of  the 
digestive  apparatus,  seriously  interfering  with  the  nutrition,  pertains  to 
the  malignant  forms  of  scarlet  fever. 

The  urine  is  high-colored,  and  in  robust  children  during  the  first 
days  of  scarlet  fever  it  frequently  deposits  urates  on  cooling.  Gee,  who 
has  carefully  investigated  the  state  of  the  urine  in  scarlet  fever,  says 
that  the  quantity  of  water  is  diminished  and  the  urea  is  not  necessarily 
increased  during  the  pyrexia;  that  the  chloride  of  sodium  is  diminished 
till  the  f()urth,  fifth,  or  sixth  day,  and  that  the  phosphoric  acid  is  dimin- 
ished during  the  climax  of  the  ])yrexia,  though  not  in  the  first  three 
or  four  days.  In  one  case  he  made  a  daily  estimation  of  the  amount  of 
uric  acid,  and  found  it  greatly  diminished  on  the  second  and  third  days, 
normal  on  the  fourth,  and  much  increased  on  the  fifth.  He  believes 
that  similar  variations  are  common  in  the  quantity  of  the  products 
excreted  in  the  urine.  Bile  may  also  appear  in  the  urine,  coincident 
with  a  yellow  tinge  of  the  conjunctiva.^ 

The  duration  of  scarlet  fever  varies  in  difierent  cases.  If  the  attack 
be  verv  mild,  with  little  efllorescence,  the  febrile  movement  may  decline 
by  the  fourth  or  fiftli_jday ;  but  if  the  disease  be  geyere,  little  or  no 
'  amelioration  of  symptoms  may  occur  before  the  twelfth^or  fourteenth 
day,  even  when  no  complication  has  occurred  to  increase  the  tempera- 
ture or  cause  aggravation  of  symptoms.  Octcrlony,  who  estimated  the 
duration  of  scarlet  fever  from  the  commencement  of  febrile  symptoms 
to  "  the  disappearance  of  fever,  with  marked  improvement  in  leading 
symptoms,"  ....  "found  that  the  ayerage  duration  of  the  disease  in 
forty  cases  was  ^ix  and  ovip-fiiy_th  days.  The  minimum  duration  in  a 
very  slightly  marked  case  was  three  (lays :  the  maximum  duration  was 
fourteen  days."  In  general,  prolongation  of  fever  beyond  the  usual 
time  is  due  to  some  complication — more  frequently  to  unusuall}'^  severe 
pharyngitis,  with  accompanying  cellulitis,  than  to  any  other  cause. 

The  malady  whose  commencement  was  so  abrupt  declines  gradually. 
In  ordinary  cases,  l)y  the  close  of  the  first  week  or  in  the  beginning  of 
the  second  the  rash  becomes  less  and  lesTHistinct,  and  finally  dis- 
appears, as  do  also  the  redness  and  swelling  of  the  buccal  and  faucial 
surfaces.  The  engorgement  of  the  tonsils  and  of  the  papilla  of  the 
tongue  subsides,  the  appetite  returns,  the  countenance  brightens  and 
becomes  natural,  and  the  child,  who  during  the  height  of  the  fever 
scarcely  noticed  objects  or  noticed  them  Avith  indifference  or  even  re- 
pugnance, can  be  amused  as  before  his  sickness. 

Desfjuamation  succeeds.  This  begins  at  about  the  gixtji_day,  and  is 
not  Completed  till  the  tenth  or  twelftliday ;  often  not  till  the  close  of 
the  third  or  in  the  fourth  week.  The  amount  of  desquamation  corre- 
sponds with  the  intensity  and  duration  of  the  efflorescence,  or  rather  of 
the  dermatitis  which  produces  the  efflorescence.  If  the  efflorescence 
have  been  slight  and  partial,  it  will  be  slight,  perha{)s  scarcely  appre- 
ciable, but  if  the  rash  have  been  general,  full,  and  j)votracted,  exfolia- 

*  Article  on  scarlatina  in  Keynolds's  System  of  Medicine. 


SYMPTOMS.  217 

tion  occurs  upon  every  part.  It  begins  about  the  face  and  neck,  and 
within  a  day  or  two  appears  upon  other  parts.  Where  the  skin  is  thin 
the  epidermis  as  it  is  detached  presents  a  furfuraceous  appearance ; 
wdiere  it  is  thick,  as  upon  the  pahns  of  the  hands  or  soles  of  the  feet,  it 
separates  in  hiyers  of  considerable  thickness. 

Such  is  a  brief  description  of  scarlet  fever  when  it  pursues  its  normal 
course  without  any  disturbing  element,  but  there  is  no  other  disease  in 
which  complications  and  sequelse  so  frequently  occur.  The  liability  to 
them  renders  the  prognosis  in  every  case  doubtful.  The>^  largely 
increase  the  percentage  of  deaths.  They  occur  both  in  mild  and  severe 
forms  of  scarlatina. 

The  difference  in  type  in  different  cases  and  epidemics  has  already 
been  alluded  to.  Scarlet' fever  is  sometimes  so  mild,  and  its  symptoms 
so  slight,  that  the  diagnosis  is  necessarily  uncertain.  In  the  spring  of 
18(36  I  was  called  to  an  infimt  thirteen  months  old  who  had  slight 
pharyngitis  and  an  indistinct  rash  over  a  part  of  the  surflice.  In  two 
days  the  eruption  had  disappeared,  and  the, health  within  a  day  or 
two  was  apparently  fully  restored.  Diagnosis  w'ould  have  been 
doubtful  except  for  sequelfe  which  clearly  indicated  the  scarlatinous 
nature  of  the  attack.  In  another  instance  two  chUdren  passed  through 
the  entire  course  of  scarlet  fever  playing  every  day  in  the  street. 
Although  the  intelligent  grandmother  saw  the  rash  ujion  them,  its 
nature  was  not  suspected,  as  it  was  midsummer  and  cases  of  prickly 
heat  common,  till  nearly  two  weeks  afterward,  when  one  of  the  chil- 
dren had  nephritis  and  anasarca  ending  fatally.  In  cases  so  mild  as 
these  the  heat  of  surface  is  but  slightly  increased,  the  pulse  but  little 
accelerated,  and  the  rash  usually  does  not  occupy  so  much  of  the 
surface  as  in  ordinary  cases;  the  appetite  is  not  lost,  though  dimin- 
ished, and  tlie  thirst  is  moderate. 

Between  scarlet  fever  so  mild  that  it  terminates  in  four  or  five  days, 
and  that  of  the  grave  or  malignant  type  presently  to  be  described,  all 
grades  of  severity  exist.  Scarlet  fever  occurs  in  all  forms  from  mild  to 
severe,  but  certain  symptoms  characterize  grave  or  malignant  cases — 
symptoms  wiiicii  are  absent  or  miu-h  less  prominent  in  ordinary  scarlet 
fever.  Therefore  the  grouping  of  cases  according  to  the  type  is  proper, 
and  it  facilitates  the  studying  of  the  disease. 

Grave  Form  (malignant  scarlet  fever). — This  form  of  the  disease  is 
in  some  epi<leinics  common,  while  in  others  it  is  rare.  The  symptoms 
wiiich  characterize  it  are  severe  from  the  b(!giiming.  those  of  the  nervous 
system  predominating  at  first,  such  as  intense  ce[)halalgia,  restlessness 
or  stupor,  sudden  twitching  of  the  muscles,  and  perha))s  delirium,  or 
even  convulsions.  Many  [)ass  rapidly  into  coma  and  die  within  two  or 
three  days,  succumbing  to  the  intensity  of  the  scarlatinous  poison  while 
the  malady  is  still  in  its  commencement.  The  rash  is  dusky.  It  dis- 
a])|)ears  by  ]»ressure,  ami  returns  slowly  Aviien  the  pressure  is  removed, 
showing  extreme  sluggishness  of  the  capillary  circulation.  Some 
patients  are  very  drowsy,  lying  in  a  semi-comatose  state  except  when 
aroused,  and  if  aroused  are  very  restless.  Others  are  constantly  rest- 
less. If  placed  in  one  position  on  the  bed,  they  throw  themselves  in 
another  in  a  half-conscious  or  unconscious  state.     They  do  not  speak. 


218  SCARLET    FEVER. 

or  tliey  mutter  like  those  affected  by  the  graver  forms  of  typhus,  calling 
the  names  of  playmates  or  talking  incoherently  about  things  which  in- 
terested them  when  well.  The  thermometer  placed  in  the  axilla  is 
found  to  rise  above  103°,  which  is  a  safe  average,  to  105°  or  even 
107°,  and  the  heat  of  the  surface  is  pungent  except  when  the  case 
approaches  a  fatal  termination,  Avhen  the  extremities,  ears,  and  nose 
may  be  cool  while  the  trunk  and  head  are  extremely  hot.  The  pulse 
from  the  first  is  rapid,  ranging  from  130  as  the  minimum  in  a  malig- 
nant case  to  a  frequency  which  can  scarcely  be  counted.  A  very 
frequent  pulse  is  nearly  always  feeble  and  compressible.  Irritability 
of  the  stomach  is  one  of  the  most  common  symptoms  in  grave  cases,  so 
that  many  patients  immediately  reject  the  nutriment  and  stimulants 
which  are  so  urgently  required  to  sustain  the  vital  powers.  The  vomit- 
incr,  therefore,  if  frequent  and  severe,  greatly  increases  the  danger,  and 
in  not  a  few  instances  this  symjitom  is  associated  with  diarrhoea,  which 
also  tends  to  increase  the  prostration. 

Severe  and  dangerous  nervous  symptoms,  due  to  the  intensity  or 
activity  of  the  scarlatinous  poison,  occur  chiefly  Avithin  the  first  three  or 
four  days.  Grinding  the  teeth,  sudden  muscular  twitching,  dehrium, 
convulsions,  and  profound  stupor  occur  for  the  most  part  Avithin  this 
time.  Afterward  the  danger  is  mainly  from  exhaustion,  uidess  in  the 
second  week  or  subsequently,  when  nervous  symptoms  may  arise  from 
urjemia. 

Those  who  survive  the  onset  of  malignant  scarlet  fever  often  have  in 
the  course  of  a  few  days  severe  pharyngitis  with  extension  of  the  in- 
flammation to  the  lymphatic  ghinds  and  connective  tissue  around  the 
angle  of  the  jaw.  These  inflammations  cause  more  or  less  external 
swelling.  The  fjiucial  turgescence  around  the  entrance  of  the  larynx, 
with  the  accompanying  secretions  of  viscid  mucus  or  muco-pus,  often 
causes  noisy  respiration,  and  many  at  this  stage  of  the  attack  breathe 
with  the  mouth  constantly  open  to  facilitate  the  ingress  of  air. 

Ordinarily-,  no  discharge  occurs  at  first  from  the  nasal  surface,  but  as 
the  disease  continues,  if  the  type  remain  severe,  defluxion  of  thin  muco- 
pus  takes  phice  from  the  Schneiderian  surfixce,  which  frc()ucntly  excori- 
ates the  cheek.     The  lips  also  are  frequently  sore  and  swollen. 

In  malignant  cases  the  disease  is  more  protracted  than  when  the  type 
is  mild.  Thus  in  a  recent  case  in  my  practice  the  rash  was  still  distinct 
at  the  close  of  the  second  week,  though  the  temperature  had  fallen  from 
105°  to  102°  and  some  desquamation  had  appeared.  Long  continuance 
of  the  febrile  movement  is,  however,  oftener  attributable  to  some  inflam- 
matory complication  than  to  the  primary  disease. 

In  all  epidemics  of  a  severe  type  cases  now  and  then  occur  in  which 
the  poison  is  so  intense,  or  it  acts  with  such  frightful  energy,  that  death 
occurs  even  Avithin  the  first  day.  The  patient  is  overpowered  at  the 
outset  of  tlie  disease  by  the  virulence  of  the  specific  principle,  perishing 
in  coma,  preceded  perhaps  by  convulsions.  The  autopsy  in  such  cases 
reveals  hypememia  of  the  brain  and  cranial  sinuses,  blood  of  a  dark  red 
color,  capillary  hemorrhages  in  various  parts,  a  flabby  heart,  and  perhaps 
some  en<iorgement  of  the  spleen  and  kidneys. 

Usually,  malignant  scarlet  fever  exhibits  its  severe  type  from  the 


IRREGULAR    FORMS,  219 

fii*st,  but  cases  sometimes  occur  which  seem  mild  and  favorable  for  a 
few  days,  when  severe  symptoms  suddenly  supervene.  This  change 
from  a  mild  to  a  dangerous  disease  is,  however,  most  frequently,  I 
think,  due  to  some  complication. 

Irregular  Forms. — Deviation  from  the  normal  type  in  scarlet  fever 
is  usually  due  to  some  perturbating  cause,  which  is  often  a  preexisting 
or  coexisting  disease,  or  a  disordered  state  of  system  through  causes  dis- 
tinct from  scarlatina.  Thus,  a  little  girl  in  my  practice  had  the  symp- 
toms of  scarlet  fever,  such  as  febrile  movement  and  iniiammation  of 
the  buccal  and  faucial  surfaces,  nearly  a  week  before  the  scarlatinous 
eruption  appeared.  During  this  time  the  patient  had  an  intestinal 
catarrh,  with  diarrhoea,  which  declined  when  the  rash  occurred.  This 
intestinal  disease  was  the  apparent  cause  of  the  irregularity  in  the 
malady.  If  scarlatina  occur  during  a  severe  attack  of  entero-colitis 
attended  by  purging,  the  defluxion  from  the  intestinal  sui'face  may  be 
such  that  no  eftlorescence  appears.  Severe  scarlet  fever  itself  some- 
times appears  to  cause  gastro-intestinal  catarrh  so  as  to  produce  an 
afflux  of  blood  toward  the  intestinal  tract  and  away  from  the  gkin. 
Practitioners  occasionally  meet  cases  like  the  following,  which  I  recall 
to  mind  :  In  a  family  where  scarlatina  was  prevailing  a  little  child 
early  after  the  commencement  of  symptoms  which  seemed  to  be  plainly 
referable  to  this  exanthem  was  seized  with  vomiting  and  purging,  Avhich 
continued  till  death  occurred  on  the  third  day.  No  efflorescence  appeared 
on  the  skin,  but  the  symptoms  indicated  the  presence  of  severe  intestinal 
catarrh,  complicating  and  masking  scarlatina.  We  are  aided  in  the  diag- 
nosis of  such  cases  by  observing  the  faucial  redness,  and  we  may  discover 
a  faint  efflorescence  upon  parts  of  the  surface,  as  about  the  groin  or  in 
the  ilexures  of  the  joints.  In  another  instance  an  infant  in  the  warm 
months,  having  protracted  entero-colitis,  the  usual  summer  epidemic 
of  the  cities,  had  the  characteristic  symptoms  of  scarlet  fever,  which 
was  present  in  the  family,  but  the  diarrhoea  continued  and  no  rash 
appeared. 

In  one  who  is  much  reduced  by  an  antecedent  disease,  especially  if, 
like  the  intestinal  catarrh  mentioned  above,  it  pi'oduces  a  decided  aflhix 
of  blood  away  from  the  surface  and  toward  the  interior  of  the  body,  the 
eruption  is  commonly  tardy  in  its  appearance,  indistinct,  or  wholly 
absent.  Thus,  severe  inflammations  of  internal  organs  not  infre- 
quently render  scarlet  fever  irregular.  On  the  other  hand,  some  mal- 
adies ocfuiring  in  connection  with  this  exanthem  do  not  change  its 
synipto.ns,  but  themselves  undergo  modification.  Pertussis  may  be  cited 
as  an  examj)le,  the  cough  of  which  is  sometimes  modified  by  an  inter- 
current attack  of  scarlet  fever,  the  symptoms  of  the  latter  disease  under- 
going little  change. 

Scarlet  fever  may  also  be  irregular  without  any  apparent  ])erturbating 
cause.  In  IMGT  I  attendc<l  a  young  lady  whose  previous  Iicalth  had 
been  good,  and  whose  brother  was  sick  at  the  time  with  scarlet  fever. 
She  had  considerable  febrile  movement,  with  severe  phurynyitis,  and, 
though  her  surface  was  repeatedly  examined,  no  efflorescence  was  seen. 
Two  Aveeks  subsequently  she  was  affected  with  severe  nephritis,  anasarca, 
effusion  into  at  least  one  of  the  pleural  cavities,  oedema  of  the  lungs,  and 


220  SCARLET    FEVER. 

according  to  my  diagnosis,  hydro-pericardium,  the  case  ending  fatally. 
Rilliet  and  Barthez  state  that  a  second  attack  of  scarlet  fever  is  more 
likely  to  be  irregular  than  the  first.  Probably  this  opinion  is  correct, 
especially  if  ordy  a  short  time  have  elapsed  between  the  two  seizures. 
Still,  as  we  have  already  stated,  both  seizures  may  be  typical,  and  the 
second  more  severe  than  the  first. 

It  would  be  impossible  to  make  a  clear  and  positive  diagnosis  of  cer- 
tain cases  of  irregular  scarlet  fever,  in  which  cerebral,  pulmonary,  or 
gastro-intestinal  symptoms  predominate,  were  it  not  for  the  fict  that 
they  occur  in  connection  with  other  cases  of  scarlet  fever  or  are  followed 
by  sequelas  which  evidently  have  a  scarlatinous  origin. 

Occasionally,  the  eruption,  if  it  be  intense  or  if  a  certain  condition  of 
system  be  present  in  the  patient,  is  accompanied  by  more  or  less  extrava- 
sation of  blood-corpuscles  from  the  capillaries,  usually  in  points,  so  that 
the  redness  does  not  entirely  disappear  on  pressure.  In  rare  instances 
certain  of  the  exanthematic  fevers  present  an  extreme  hemorrhagic  char- 
acter, so  as  to  be  beyond  the  reach  of  remedies,  and  of  necessity  speedily 
fetal.  Hemorrhagic  cases  of  this  severe  form  are  probably  more  com- 
mon in  variola  than  in  the  other  fevers,  but  I  have  met  a  notable  case 
in  Avhat  was  diagnosticated  scarlatina.  In  June,  1881,  a  man  in  his 
thirty-second  year,  whose  previous  health  had  not  been  good,  though  he 
had  no  defined  ailment  and  had  been  able  to  follow  his  occupation  of 
harness-maker,  suddenly  became  very  ill,  Avith  high  febrile  movement 
and  faucial  inflammation,  attended  by  marked  prostration.  After  some 
hours  an  intense  eruption  of  a  scarlatinous  appearance  covered  nearly 
the  entire  surface,  and  on  the  following  day  hemorrhages  began  to  occur. 
The  urine  contained  a  large  proportion  of  blood;  each  conjunctiva  was 
raised  by  hemorrhages  underneath  (ecchymosis),  so  that  its  natural 
color  was  lost,  the  eyelids  Avere  closed  with  difficulty,  and  blood  flowed 
from  the  nostrils,  gums,  and  under  the  skin,  forming  hemorrhagic 
points  and  blotches.  One  of  the  consulting  physicians,  perceiving  the 
resemblance  to  hemorrhagic  variola  as  described  by  Hebra,  suspected 
that  we  had  a  case  of  this  formidable  malady  to  deal  with,  but  the  time 
for  the  appearance  of  the  variolous  eruption  passed  by  without  its  oc- 
currence. Death  took  place  on  the  fifth  day.  The  temperature  during 
the  sickness  was  high,  though  the  record  of  it  has  been  mislaid.  For- 
tunately, such  severe  hemorrhagic  cases,  which  are  necessarily  fatal, 
are  rare. 

Complications  and  Sequel^.. — Scarlet  fever,  if  its  type  be  severe, 
is  in  itself  dangerous  to  life.  Many,  as  we  have  seen,  perish  from  its 
direct  effects  when  it  produces  profound  bliKxh^poisoiiing.  But,  Avhile 
the  ordinary  epidemics  of  this  malady  are  necessarily  attended  by  a  large 
mortality  from  the  virulence  and  depressing  effect  of  the  specific  princi- 
ple, unfortunately,  of  all  the  diseases  of  modern  times,  scarlatina  ranks 
first  as  regards  tlie  number  and  gravity  of  its  complications  and  se(]uelcTe, 
so  that  nearly  or  quite  as  many  perish  from  these  as  from  the  direct 
effects  of  the  poison. 

Nervous  accidents  occur  chiefly  at  two  periods — to  wit,  in  the  first 
days,  when  they  are  due  to  the  severity  and  malignancy  of  the  malady 
and  to  the  impressible  nervous  temperament  of  the  child,  and  in  the  de- 


C0MPLICATI0X3    AXD    SEQUELAE.  221 

dining  stage,  or  after  the  termination  of  the  fever,  when  they  occur  from 
uraemia.  If  the  type  be  malignant,  delirium,  jactitation,  profound  stu- 
por, and  convulsions  frequently  occur  on  the  first  and  second  days;  and 
these  are  symptoms  Avhich  properly  excite  the  utmost  alarm  and  demand 
all  the  resources  of  our  art,  since  they  indicate  a  form  of  the  disease 
■which  frequently  ends  in  speedy  death.  The  eyes  have  a  dull  or  wild 
expression,  the  conjunctiva  is  suffused,  the  heat  of  surface  pungent,  the 
pulse  rapid  and  compressible  or  feeble,  rising  above  150,  even  to  200, 
per  minute,  and  the  temperature  is  always  elevated  to  a  degree  that  in- 
volves danger,  the  thermometer  not  infrequently  indicating  105°  or  106°. 
But  this  severe  form  of  scarlet  fever,  attended  by  so  great  elevation  of 
temperature,  is  much  less  dangerous  than  in  former  times,  even  though 
it  be  complicated  by  delirium  and  convulsions,  since  we  no  longer  hes- 
itate to  reduce  bodily  heat,  "when  excessive,  by  the  free  use  of  cold  baths, 
and  have  discovered  potent  agents  in  the  bromides  and  cldoral  for  con- 
trolling convulsions.  Nevertheless,  not  a  few  perish  in  the  commence- 
ment of  scarlet  fever  with  predominating  cerebral  symptoms,  as  delirium 
or  eclampsia,  followed  by  coma,  under  the  best  possible  treatment. 
Sometimes  the  symptoms  have  closely  simulated  those  of  acute  menin- 
gitis, and  if  the  rash  have  been  delayed  and  the  sore  throat  is  as  yet 
slight,  the  physician  may  suspect  that  he  is  dealing  Avith  this  disease; 
but  autopsies  in  such  cases  show  no  inflammatory  lesions,  but  only  con- 
gestion of  the  cerebral  and  meningeal  vessels. 

As  is  stated  in  a  preceding  page,  in  every  case  of  normal  scarlet  fever 
inflammation  of  the  faucial  surface  is  present,  as  indicated  by  redness, 
tenderness,  and  increased  secretion  of  mucus  or  muco-pus.  It  precedes 
the  efflorescence  on  the  skin,  and  is  announced  by  pain  in  swallowing 
and  on  pressure  with  the  fingers  behind  and  below  the  angles  of  thejaw. 
In  that  form  of  scarlet  fever  which  has  been  designated  anginose  the 
pharyngitis  is  severe,  and  is  a  prominent  element  in  the  malady,  the 
uvula,  the  pillars  of  the  fauces,  and  the  faucial  surface  in  general  being 
infiltrated  and  swollen.  Nevertheless,  this  inflammation,  with  the 
accompanying  tumefaction,  is  properly  a  part  of  the  disease,  rather 
than  a  complication,  if  it  abate  with  the  subsidence  of  the  scarlet  fever 
or  begin  to  abate  soon  after,  and  if  it  produce  but  slight  destructive 
change  in  the  tissue  of  the  neck.  The  secretions  from  the  fiiuccs  may 
be  foul  and  offensive  ;  even  superficial  ulcerations  or  gangrene  may 
occur  upon  the  faucial  surface,  causing  it  to  present  a  dark  brown  or 
jagged  appearance,  and  the  tissues  of  the  neck  may  be  infiltrated  to  a 
certain  extent,  and  we  designate  the  disease  a  form  of  scarlet  fever 
under  the  title  anginose.  But  when  this  condition  is  greatly  aggra- 
vated, so  that  extensive  infiltration  and  swelling  of  the  tissues  of  the 
neck  occur,  with  an  amount  of  ulceration  or  gangrene  which  in  itself 
involves  danger,  continuing  after  the  primary  disease  abates,  prolonging 
the  fever  anrl  reducing  the  strength,  it  is  proper  to  regard  the  state  of 
the  throat  as  a  complication.  In  addition  to  the  pharvTigitis,  which  is 
severe  as  described  above,  the  sides  of  tiie  neck  around  the  angles  of 
thejaw  become  swollen,  hard,  and  tender.  The  inflammation  has  been 
propagated  to  the  deeper  structures  of  the  neck.  Poisonous  substances, 
the  result  of  decomposition  or  vitiated  secretions,  traverse  the  lymphatic 


222  SCARLET    FEVER, 

vessels  from  the  faucial  surface,  and,  being  intercepted  in  the  lymphatic 
glands,  cause  adenitis,  and  the  inflammation  extends  from  the  glands  to 
the  adjacent  connective  tissue,  which  becomes  hard,  tender,  swollen,  and 
infiltrated  with  inflammatory  products.  This  tumefaction  sometimes 
begins  by  the  second  or  third  day,  but  it  is  usually  about  the  close  of 
the  firjt  week  or  in  the  beginning  of  the  second  Aveek  that  it  becomes  so 
considerable  as  to  constitute  a  source  of  danger  and  anxiety.  It  is  in 
most  cases  bilateral,  though  one  side  may  begin  to  swell  before  the 
other  and  remain  larger  throughout. 

In  severe  cases  of  this  complication  the  tumefaction  extends  from  £jii' 
to  ear,  filling  up  the  space  below  and  around  the  angles  of  the  jaw  and 
uncTei'  the  chin.  Xot  only  is  deglutition  difficult,  but  it  is  difficult  to 
open  the  mouth  sufficiently  to  inspect  the  fauces,  and  attempts  to  do  so 
cause  much  pain.  The  lymphatic  glands,  which  lie  in  the  inflamed 
area  and  participate  in  the  inflammation,  are  greatly  enlarged  by  hyper- 
plasia, the  round  granular  lymph  cells  multiplying  so  abundantly  that 
the  glands  increase  to  many  times  their  normal  size.  Most  of  the 
tumefaction  is,  however,  due  to  extension  of  the  inflammation  to  the 
connective  tissue  of  the  neck.  The  cellulitis,  which  resembles  that 
occurring  in  other  conditions,  is  attended  by  distention  of  the  capil- 
laries, the  abundant  formation  of  young  round  cells,  and  transudation 
of  serum  (Billroth).  A  moderate  amount  of  tumefaction  may  disappear 
by  resolution,  but  if  it  be  considerable  it  seldom  abates  in  this  way,  but 
by  the  tedious  and  exhausting  process  of  suppuration  or  gangrene.  If 
the  swelling  at  its  most  prominent  point  present  a  reddish  hue,  all  hope 
of  producing  resolution  must  be  abandoned  ;  it  cannot  be  effected  by 
any  medicine  or  appliance  within  the  resources  of  our  art.  The 
abscess  which  forms  is  likely  to  be  diffuse,  so  as  to  involve  danger  of 
pyremia,  unless  it  be  soon  opened  and  properly  washed  out.  With  the 
discharge  of  the  pus  the  swelling  gradually  softens  and  declines.  In 
other  cases  gangrene  results.  The  vessels  in  the  inflamed  part  are  com- 
pressed by  the  inflammatory  products,  so  that  they  no  longer  convey  the 
blood  which  is  required  for  the  purpose  of  nutrition.  It  is  a  law  of 
the  economy  that  whenever  the  circulation  ceases,  the  tissues  which 
receive  their  nutritive  supply  through  the  obstructed  vessels  lose  their 
vitality.  Hence  gangrene  occurs  in  all  that  portion  of  the  swelling  in 
which  the  circulation  is  arrested.  The  skin  over  it  peels  off",  the  dead 
tissue  underneath  is  brown  or  dark,  and  soon,  if  life  be  prolonged,  the 
slough  begins  to  separate.  The  prognosis  as  regards  this  complication 
depends  largely  on  the  size  of  the  slough.  If  it  be  large,  death  will 
probably  result,  since  the  strength  of  the  system  is  already  reduced  by 
the  primary  disease,  and  the  reparative  process  will  necessarily  be  slow, 
while  abundant  suppuration  tends  to  increase  the  exhaustion.  In  some 
of  the  worst  cases  of  cervical  gangrene  which  I  have  seen  the  slough 
has  laid  bare  the  muscles  and  vessels  of  the  neck,  producing  in  one 
case  a  cavity  or  excavation  sufficiently  large  to  admit  a  hen's  egg. 
Often  the  slough  extends  under  the  skin,  so  that  the  deepest  recesses 
of  the  cavity  are  not  visible,  and  occasionally  in  cases  which  have  ended 
fatally  in  my  practice  severe  hemorrhage  occurred  from  the  concealed 
vessels.     If  the  ulcerative  or  gangrenous  process  extend  so  deeply  into 


CO  MP  Lie  ATI  OXS    AXD    SEQUEL.E.  223 

the  tissues  of  the  neck  that  hemorrhages  occur,  death  is  the.  common 
result ;  but  if  -the  destructive  action  be  of  moderate  extent  and  other 
conditions  favorable,  we  may  expect  recovery  through  cicatrization, 
■svith  perhaps  some  deformity  by  contraction  of  the  cicatrix. 

When  the  inflammation  of  the  connec^^e  jtissue  of  the  neck  is  exten- 
sive, involving  botlTlthe  lateral  and  anterior  regions  of  the  neck,  t!\e 
patient  is  in  a  perilous  state.  The  cellulitis,  when  extensive  and  accom- 
panied by  much  swelling,  may  produce  oedema  of  the  .glottis,  may 
obstruct  respiration  by  compressing  the  air-passages  or  the  laryngeal 
nerves,  may  cause  compression  of  the  jugular  veins,  and  thus  give  rise 
to  dangerous  cerebral  symptoms,  or  may  lay  bare  and  injure  important 
muscles  and  nerves,  as  we  have  seen.  If  the  ulceration  or  gangrene 
be  extensive,  and  death  do  not  occur  by  hemorrhage  from  arterial  or 
venous  twigs,  septic  poisoning  may  occur,  increasing  still  more  the  fatal 
nature  of  the  malady. 

Some  cases  of  this  complication  are  melancholy  in  the  extreme,  as 
one  related  by  Cremen,  in  which  ulceration  of  the  pharynx  occurred, 
allowing  the  escape  of  food  and  preventing  deglutition.  In  severe  scar- 
latinous pharyngitis  the  inflammation  sometimes  extends  along  the 
Eustachian  tube,  causing  its  occlusion.  This  accident  will  be  con- 
sidered when  we  treat  of  otitis  media,  another  grave  complication.  It 
often  also  extends  into  the  nares,  causing  catarrh  of  the  Schneiderian 
mucous  membrane,  with  discharge  of  muco-pus  from  this  surface.  Not 
infrequently  ulceration  or  gangrene  occurs  in  the  faucial  surface,  pro- 
ducing; more  or  less  destruction  of  tissue  and  formino;  excavations  which 
connect  with  the  throat,  while  the  cutaneous  surface  retains  its  integrity 
and  is  not  even  reddened.  The  following  case  shows  how  grave  the 
complication  which  we  are  now  considering  sometimes  is  when  the  ex- 
ternal surfoce  of  the  neck  is  not  involved,  and  how  the  inflammation 
by  extension  outward  from  the  fauces  may  involve  the  middle  ear. 

Case  1. — Annie  K ,  aged  two  and  a  half  years,  and   inmate  of 

the  New  York  Foundling  Asylum,  was  well,  except  an  eczema  of  the 
sculp,  until  the  night  of  April  3,  18^2,  when  siie  was  attacked  with  vomit- 
ing and  diarrhoea.  She  was  feverish  and  drowsy,  and  at  2  P.  M.  on  the 
4th  the  scarlatinous  efflorescence  appeared  upon  her  neck,  body,  and 
lower  extremities  ;  tongue,  coated  ;  pharynx  red  ;  temperature  (axillary) 
lOo' ;  pulse  160.  The  symptoms  and  aspect  indicated  a  grave  form  of 
tlie  miiady,  ami  the  usual  sustaining  treatment  was  ordered.  On  Ajiril 
5th  the  temperature  was  102',  pulse  144,  tongue  less  coated,  eruption 
fadnig,  less  stupor,  no  albumen  in  urine.  April  6th,  morning  temperature 
102%  pulse  160;  passed  a  restless  night;  stools  thin  and  too  frequent; 
has  grayish  patches  in  the  throat ;  p.  M.  temperature  lOoi',  pulse  loO. 
April  7th,  the  diarrhrea  continues,  and  she  has  a  copious  niueo-puruk'nt 
discharge  from  the  nostrils;  p.  M.  temperature  lOof,  pulse  160.  April 
10th,  the  temperature  has  continued  at  about  103°;  the  patient  is  very 
sick,  with  a  constant  foul-smelling  discharge  from  the  nostrils;  breath 
very  offensive ;  tera))erature  103.5%  pulse  about  180.  April  Tith,  general 
appearance  a  little  better,  but  the  posterior  surface  of  the  fauces  is  com- 
pletely covered  by  a  thick  pseudo-membrane;  had  four  loose  stools  last 
night ;  temperature  and  pulse  the  same  as  at  last  record ;  a  dark,  offen- 


224  SCARLET    FEVER. 

sive,  and  jagged  coating  over  the  fliuces,  and  a  dark,  foul  discharge  from 
the  nostrils,  as  before;  examination  of  the  chest  negative.  April  14th, 
is  much  prostrated;  temperature  104.5^,  pulse  rapid  and  weak;  respira- 
tion noisy,  diminished  resonance  over  lower  two-thirds  of  left  side  of 
chest ;  ulcers  upon  the  mouth  and  tongue ;  fauces  red  and  ulcerated. 
April  17th,  pulse  150,  temperature  100.5';  general  appearance  somewhat 
better,  but  the  diarrhoea  continues,  and  patches  of  a  diplitheritic  char- 
acter have  appeared  upon  the  lips ;  moist  rales  in  left  side  of  chest.  The 
symptoms  continued  nearly  the  same  until  April  23d,  when  she  died.  A 
dull  percussion  sound  and  distinct  bronchial  respirati(m  were  observed  in 
the  left  scapular  region  daring  the  last  days  of  her  life. 

Autopsy  nine  hours  after  death  by  the  curator,  Dr.  W.  P.  Northrup: 
Body  well  nourished ;  the  tissues  have  a  jaundiced  hue ;  lips  sore ;  on 
turning  the  head  to  one  side  pus  runs  from  the  left  ear  and  dirty  muco- 
pus  from  the  mouth.  Brain  normal ;  on  opening  the  petrous  portion  of 
the  left  temporal  bone  the  middle  ear  is  found  i'ull  of  pus,  which  com- 
municated freely  with  the  external  ear  through  a  perforated  memlirana 
tympani ;  the  Eustachian  tube  cannot  be  traced  in  the  sloughy  tissue, 
and  a  passage  filled  with  pus  extends  from  the  ear  to  the  fauces;  opposite 
the  greater  cornua  of  the  hyoid  bone  are  two  deep  ulcers,  each  having 
about  the  diameter  of  a  ten-cent  piece,  with  sloughy  and  offensive  base 
and  sides;  the  left  ulcer  communicates  by  a  ragged  and  wide  sinus  with 
a  dark  and  sloughy  cavity  of  about  four  drachms  capacity;  this  cavity  is 
located  in  the  neck  under  the  angle  of  the  jaw,  apparently  occu|)ying  the 
site  of  a  disintegrated  gland,  and  it  opens  upon  the  surface  of  the  fauces. 
The  surface  of  the  larynx  has  a  dusky,  dirty  appearance,  sprinkled  with 
little  cheesy-looking  spots,  and  covered  by  a  dirty,  foul-appeai'ing  liquid, 
as  if  some  of  the  ichorous  pus  had  escaped  into  it  from  the  neck  ;  about 
one  and  a  half  inches  below  the  vocal  chords  there  is  an  unmistakable 
pseudo  memln-ane ;  below  this,  near  the  bifurcation,  the  trachea  has  a 
bright-red  color,  as  if  a  pseudo-membrane  had  been  peeled  from  it, 
leaving  the  surface  raw.  The  detachment' of  a  pseudo-membrane  from 
this  part,  if  it  did  occur,  must  have  been  ante-mortem,  for  the  organ  had 
been  carefully  handled  in  making  the  autopsy.  Between  the  apex  of  the 
left  lung  and  the  median  line  the  tissues  of  the  neck,  dissected  upward, 
are  found  indurated,  yellow,  and  giving  an  offensive  odor,  showing  that 
the  cervical  cellulitis  had  extended  downward  further  than  usual.  The 
bronc'iial  glands  have  undergone  hyperplasia,  being  enlarged  and  hard. 
The  right  lung  is  normal;  about  one-half  of  the  left  lower  lobe  is  con- 
solidated, and  when  cut  is  found  to  be  gangrenous  and  offensive.  The 
liver  is  apparently  somewhat  enlarged;  spleen  normal  in  size;  gastric 
mucous  membrane  has  a  congested  ai)pearance  and  is  covered  with 
mucus;  mesenteric  glands  enlarged,  pale,  and  firm;  Peyer's  patches 
swollen  and  pale ;  at  lower  end  of  ileum  some  pigmentation  of  these 
glands;  in  large  intestine  the  solitary  glands  are  enlarged,  and  a  few  of 
them  pigmented ;  kidneys  pale,  cortex  thickened,  and  markings  indis- 
tinct. Microscopical  Examination. — In  the  pia  mater  perhaps  a  little 
increase  of  cells;  meninges  of  brain  otherwise  normal.  Tlie  trachea 
shows  well-marked  diphtheritic  inflammation;  it  contains  a  film  of 
pseudo-membrane ;  evidences  of  inflammation  occur  also  upon  the  Inryn- 
geal  surface,  though  less  marked  tlian  in  the  trachea.  The  solidified 
portion  of  the  lun^:  exhibits  the  ordinarv  le-ions  of  broncho-pneumonia, 
with  some  interstitial  change.  In  the  kidneys  we  find  parenchymatous 
nephritis,  with  some  cell-growth  in  the  Malpighian  bodies. 


COMPLICATIOXS    AXD    SEQUELAE.  225 

The  above  case  has  been  related  at  length,  not  only  because  it  shows 
how  severe  and  destructive  the  inflammation  of  the  throat,  extending 
into  the  tissues  of  the  neck,  sometimes  is,  but  because  four  other  com- 
plications or  sequelse  were  also  present — to  wit,  otitis  media,  diphtheria, 
nephritis,  and  pneumonia.  We  see  how  formidable  a  disease  scarlet 
fever  sometimes  is  when  attended  by  the  inflammations  to  which  it  so 
frequently  gives  rise,  for  a  child  older  and  stronger  than  this,  if  thus 
affected,  would  inevitably  have  perished  with  the  best  possible  treatment. 

In  localities  Avhere  diphtheria  is  endemic,  as  in  New  York  City  and 
Paris,  scarlet  fever  is  often  complicated  by  pseudo-membranous  inflam- 
mation of  the  fauces  and  air-passages.  In  severe  cases  the  Schneiderian 
as  well  as  the  faucial  surface  is  covered  with  pseudo-inenibnine,  so  that 
it  can  be  readily  seen  on 'inspecting  the  anterior  nares.  Occasionally, 
this  exudation  appears  upon  the  laryngeal  and  tracheal  surfaces,  as  in 
the  case  which  I  have  related  above  and  in  others  presently  to  be  related, 
causing  dangerous  embarrassment  of  respiration.  This  complication 
sometimes  begins  aluiost  at  the  commencement  of  scarlet  fever,  but  in 
most  instances  it  does  not  occur  before  the  tWd  or  fourth  day,  and  it 
sometimes  does  not  appear  tjU  in  the  declhiin^  stage  of  the  fever.  When 
it  begins,  it  intensifies  the  febrile  movement  and  produces  general  aggra- 
vation of  symptoms. 

The  elaborate  treatise  by  Sanne,  of  Paris,  on  diphtheria  contains  a 
chapter  entitled  ''Secondary  Diphtheria."  In  it  the  author  says,  what 
all  who  are  familiar  with  diphtheria  will  agree  to,  that  secondary  diph- 
theria does  not  differ  in  nature  from  the  primary  form,  and  that  it 
exhibits  a  tendency  "to  occupy  the  organs  which  are  themselves  the 
seat  of  the  more  pronounced  local   determinations  of  the    primitive 

malady Dii)litheria  is  seen  in  the  course  or  sequel  of  numerous 

diseases.  Some  appear  to  have  a  special  proclivity  for  engendering 
diphtheria ;  these  are  specific  maladies :  measles,  scarlet  fever,  per- 
tussis." Sannes  statistics  relating  to  the  seat  of  scarlatinous  diphthe- 
ritic exudation  are  as  follows : 

Fauces  alone  attacked  ........  15  cases. 

Fauces  wiih  larynx  attacked         .         .         .         .         .         .  4  " 

Fauces  with  nasal  fossa  attacked           .         .         .         .         .  8  " 

Fauces  with  larynx  and  nasal  fossa  attacked         .         .         .  4  " 

Fauces  with  larynx  and  bronchi  attacked    .         .         .         .  1  " 

Fauces  with  nasal  fossa  and  lips  attacked     .         .         .         .  1  " 

Fauces  with  lips  and  skin  attacked       .         .         .         .         .  1  " 

Fauces  uiiatfected           ........  3  " 

Diphtheria  tjeneralized          .          ......  2  " 

Larynx  only  affected    ........  2  " 

Nasal  fossa    ..........  1  " 

The  opinion  of  so  good  an  observer  as  Sanne,  that  when  in  scarlet  fever, 
]iseudo-membranous  exudation  appears  upon  the  mucous  surfaces  which 
are  the  seat  of  scarlatinous  iiillammation,  diphtheria  has  supervened, 
and  not  a  croupous  form  of  scarlatinous  phlegmasia,  carries  with  it 
2reat  weight. 

Nevertheless,  one  of  the  most  difficult  pro1)loms  which  we  nave  to 
deal  with  in  certain  cases  is  to  distinguish  diphtheritic  from  non-diph- 
theritic inflammation;  and  I  see  no  reason  why  the  scarlatinous  inflam- 

15 


226  SCARLET    FEVER. 

motion  when  intense  may  not  be  sometimes  membranous.  We  know 
that  in  some  cases  of  dysentery  a  fibrinous  exudation  occurs  upon  the 
surfoce  of  the  colon  ;  that  in  croupous  pneumonia  fibrin  exudes  into  the 
bronchioles  and  alveoli  of  the  lungs ;  and  that  physicians  in  localities 
where  there  is  no  diphtheria  meet,  though  at  long  intervals,  cases  which 
they  designate  croupous  pharyngitis  and  laryngitis;  and  it  seems 
probable  that  the  intense  inflammation  of  anginose  scarlatina  some- 
times produces  the  same  exudation.  Moreover,  it  is  very  difficult  to 
distinguish  in  the  swollen  fauces  between  a  membranous  exudation  and 
ulceration  or  superficial  gangrene  so  common  in  malignant  scarlet  fever. 
The  grayish-white  surface,  jagged  and  foul,  may  be  the  one  or  the  other, 
an  exudation  or  a  sphacelus,  and  in  certain  instances  it  is  impossible  to 
discriminate  between  the  two  conditions  at  the  bedside. 

Dij^htheria  complicating  scarlet  fever  occasionally  begins  nearly  simul- 
taneously with  the  latter.  Henoch  states  that  exceptionally  he  has 
observed  suspicious  patches  upon  the  fauces  before  the  appearance  of 
the  scarlatinous  eruption  upon  the  skin  ;  and  he  adds :  ''  I  have  had 
repeated  opportunities  of  observing  this  unusual  beginning.  In  such 
cases  we  must  ask  ourselves  whether  the  first  affection  was  really  con- 
nected with  the  second,  or  Avhether  the  former  was  a  true  primary  diph- 
theria, rapidly  followed  by  scarlatina.  This  opinion  is  favored  by  the 
fact  that  I  had  only  observed  such  cases  in  the  hospital,  in  which  infec- 
tion with  various  forms  of  contagion  can  scarcely  be  avoided." 

But  usually  it  is  not  till  the  third  or  fourth  day  of  scarlet  fever  that 
this  complication  begins.  The  patient  has  been  progressing  favorably 
with  the  fever,  till  on  a  certain  day  a  marked  aggravation  of  symptoms 
occurs.  A  higher  temperature,  more  pungent  heat,  and  the  physiog- 
nomy of  a  more  serious  malady  are  present.  On  inspecting  the  fauces 
to  discover  the  cause  we  observe  a  pellicle  forming  upon  the  tonsils 
and  perhaps  other  portions  of  the  faucial  surface.  Often  the  entire 
aspect  of  the  case  changes  by  the  occurrence  of  this  complication,  a 
mild  case  of  scarlet  fever  becoming  grave  and  fatal  in  consequence. 
Thus  in  a  case  which  I  saw  with  Dr.  Hardy,  of  New  York,  the  mem- 
branous inflammation  of  diphtheria,  commencing  upon  the  fauces  on 
the  third  day  of  scarlet  fever,  extended  to  the  Sclmeiderian  membrane, 
and  tlience  along  the  left  lachrymal  sac  to  the  eyelids,  producing  redness 
and  swelling  along  the  side  of  the  nose  and  upon  the  cheek  like  that  of 
erysipelas.  A  thick  diphtheritic  pellicle  occurred  upon  the  under  surface 
of  each  eyelid  on  the  left  side,  with  great  tumefaction  of  both  lids,  gan- 
grene of  the  cornea,  and  destruction  of  the  eye.  The  case  soon  ended 
fatally. 

A  pellicular  exudation  sometimes  occurs  in  the  larynx  and  trachea 
during  the  course  of  scarlet  fever,  as  a  thin  film,  rendering  the  respira- 
tion noisy,  but  the  development  of  a  thick  and  firm  pseudo-membrane, 
so  as  to  imperil  the  life  of  the  patient  from  the  stenosis  in  the  air- 
passages,  has  been  much  less  frequent  in  my  practice  than  it  is  in 
primary  diphtheria  and  in  diphtheria  complicating  measles  or  pertussis. 
The  following  were  cases  of  this  severe  complication  occurring  in  a 
recent  epidemic  in  the  New  York  Foundling  Asylum.  In  these  cases 
the  respiration  was  noisy,  but  the  obstruction  to  breathing  was  apparently 


COMPLICATIONS    AXD    SEQUELAE.  227 

due  to  infiltration  and  swelling  around  the  aperture  of  the  glottis,  more 
than  to  the  pseudo-membrane,  which  the  autopsies  showed  to  be  present. 

Case  2. — A  child  aged  three  and  a  half  years,  who  pi'eviously  had 
svmi)toms  of  mild  catarrhal  croup,  with  moderate  redness  of  the  fauces, 
sickened  with  scarlet  fever  on  Oct.  1,  1882,  the  rash  being  profuse  and 
soon  covering  nearly  the  entire  body.  The  axillary  temperature  was 
lOo^,  pulse  140;  slight  stridor  in  breathing  and  some  cough  ;  fauces  very 
red,  but  free  from  membrane.  Oct.  2d,  restless,  sleeping  but  little ;  has 
vomited  four  times.  Oct.  3d,  temp.  103. 5"^,  pulse  120 ;  fauces  much 
swollen;  still  vomiting;  rash  abundant.  4  p.m.,  temp.  104.3^,  pulse 
128;  tongue  clean;  some  discharge  from  nares ;  urine  not  albununous, 
but  its  quantity  diminished.  Oct.  4th,  aspect  that  of  very  severe  sick- 
ness ;  profuse  discharge  from  nostrils ;  fauces  of  a  deep  red  color,  and  a 
pseudo-membrane  over  tonsils  and  uvula;  tumefaction  along  the  sides 
of  th'i  neck;  temp.  104°,  pulse  140;  breathing  moderately  stridulous ; 
urine  is  passed  more  freely  than  yesterday;  evening  temp.  105^.  Oct. 
6th,  cronpy  symptoms  more  marked ;  tonsils  ai^id  uvula  greatly  swollen, 
so  that  the  fauces  are  almost  occluded  ;  temp.  103.5°  breatliing  difficult, 
but  apparently  sufficient  oxygen  is  received  ;  profuse  nasal  discharge, 
and  other  symptoms  as  before.  About  1.30  r.  M.  he  was  raised  to  take 
some  milk,  and  suddenly  became  asphyxiated.  His  face  was  dusky,  the 
eyes  protruded,  and  he  voided  urine  and  feces.  Dr.  Swift,  who  attended 
the  child,  and  to  whom  I  ana  indebted  for  this  histoiy,  immediately  per- 
formed tracheotomy,  which  gave  temporary  relief  by  the  expulsion  of  a 
considerable  quantity  of  pseudo-membrane  through  the  opening.  On 
the  following  day  the  respiration  again  became  obstructed  at  some  point 
below  tlie  canula,  so  tliat  it  couhl  not  be  removed  ;  the  features  grew 
livid,  and  death  occurred  in  convulsions  twenty-six  hours  after  the 
tracheotomy. 

The  autopr-.y  was  made  by  Dr.  W.  P.  Northrnp,  curator  of  the  Asylum, 
who  found  the  pharynx  covered  by  a  membrane  which  was  traced  to  the 
y)f)sterior  nares ;  larynx,  trachea,  and  bnmchial  tubes  as  far  as  the  third 
divisions,  covered  with  membrane  ;  portions  of  the  tracheal  surface  de- 
nuded, and  the  mucous  membrane  underneath  of  a  bright  red  color  and 
smooth. 

Case  3. — Katie,  aged  six  and  a  third  years,  was  returned  to  the  Asylum 
on  Nov.  18th.  Three  days  later  (Nov.  21st)  she  had  sore  throat,  red- 
dened fauces,  coated  tongue,  and  a  faint  rash  upon  the  neck,  chest,  and 
arms;  eyes  injecte<l ;  temp.  102'.  In  the  afternoon  temp.  103';  eruption 
still  f:unt.  Nov.  22d,  temp.  103.5°  ;  an  eruption  on  chest,  alxlomen,  arms, 
an<l  legs  in  patches.  Evening,  temp.  104°  ;  voice  (ilear.  Nov.  23d,  temp. 
103.5';  toni.nie  red;  f  uu' 'S  deeply  reddened,  but  without  any  visible 
pseiulo-mcmbrane ;  the  scarlatinous  ernption  has  aj)peare<l  over  a  consid- 
erable part  of  the  surface.  On  the  24th  a  ))st'udo-membrane  occurred 
over  the  tonsils  and  adjacent  faucial  SMrface;  her  respiration  becauKJ 
labored,  and  death  took  place  from  dyspno-a  at  11  r.  M. 

Autopsy:  Naso-pharynx  covered  by  a  thick  fibro-purulent  membrane. 
Larynx  contains  a  well-marked  pseudo-membrane,  but  not  continuous. 
Trachea  covered  by  a  pseudo-membrane,  continuous  over  most  of  its  sur- 
face, but  in  places  broken  and  (laky.  Where  it.  is  detached  the  mucous 
membrane  is  seen  underneath,  dusky  and  deeply  injected.  At  tlie  root 
of  the  hiufrs  the  pseudo-membrane  can  be  traced  alonu;  the  tubcn  about 
an  inch  in  all  directions.     Nothing  noteworthy  in  the  other  lesions. 


228  SCARLET    FEVER. 

In  a  fourth  case  of  scarlet  fever,  in  which  death  occurred  after  an  ill- 
ness of  three  weeks  and  from  gradually  increasing  dyspncca,  it  is  stated 
in  the  records  of  the  autopsy  that  the  larynx  was  free  from  a  pseudo- 
membrane;  a  thin  film  extended  over  a  considerable  part  of  the  trachea. 

Cor^^za  frequently  commences  at  or  about  the  time  of  the  pharyn- 
gitis. The  inflammation  of  the  Schneiderian  membrane  is  continuous 
posteriorly  with  that  of  the  fauces,  and  is  announced  by  redness  and 
swelling,  inability  to  breathe  freely  through  the  nostrils,  and  an  irri- 
tating ichorous  discharge.  Simple  coryza  in  itself  involves  little  danger, 
though  it  IS  an  unpleasant  complication,  and  in  the  nursing  infant  it  may 
interfere  with  suckling.  Diphtheritic  coryza,  on  the  other  hand,  wdiicli 
is  frequently  present  when  diphtheria  complicates  scarlet  fever,  involves 
danger,  since  it  is  apt  to  cause  ulcerations,  hemorrhages,  and  septic 
poisoning.  When  the  local  symptoms  are  unusually  severe  and  the  dis- 
charge abundant,  it  is  probable  that  intlammation  has  in  some  cases 
extended  to  the  antrum  of  liighmore. 

Inflamination  of  the  middle  ear  is  another  unpleasant  and  not  infre- 
quent complication.  It  is  due  to  extension  of  the  catarrh  from  the 
pharynx  along  the  Eustachian  tube  to  the  tympanum.  In  a  consid- 
erable proportion  of  cases  of  otitis  media  this  tube  is  occluded  by  the 
infiltration  and  swelling  of  its  mucous  membrane,  so  that  the  muco-pus 
escapes  with  difficulty  or  is  retained.  Hence  s^'ejie  earache,  an  increase 
of  the  febrile  movement,  and  outward  bulging  of  the  membrana  tym- 
pani  occur.  Sometimes  headache  or  other  cerebral  symptoms  arise, 
probably  from  the  fxct  that  the  meningeal  artery,  which  supplies  the 
meninges,  is  connected  by  anastomosing  branches  with  the  tymj)anum. 
In  one  of  the  cases  related  above  it  will  be  recollected  that  the  ulcera- 
tion and  abscess  extended  from  the  fauces  to  the  middle  ear,  the  entire 
Eustachian  tube  having  disappeared  in  the  ulcerative  process. 

Frequently,  the  otitis  escapes  detection,  its  symptoms  being  masked 
or  obscured  by  the  general  disease,  until  the  membrana  tympani  is 
perforated  and  otorrhoea  begins;  but  by  careful  examination  the  nature 
of  the  complication  can  usually  be  ascertained  before  the  ear  is  injured 
to  this  extent,  for  a  patient  too  young  to  speak  will  often  press  with 
the  fingers  against  the  painful  ear  or  lie  with  the  ear  pressed  upon  the 
pillow,  evidently  having  an  increase  of  suffering  if  placed  in  any  other 
position.  One  old  enough  to  speak  and  in  proper  mental  condition 
makes  known  the  earache  as  soon  as  it  occurs. 

The  mucous  membrane  of  the  tymi)anum,  red  and  sv/ollen  from 
inflammation,  secretes  muco-pus  abundantly;  and  this,  pent  up  in  the 
cavity,  must  obtain  an  exit  before  relief  occurs.  It  is  Avell  if  the  secre- 
tion escape,  though  with  difficulty,  down  the  Eustachian  tube.  The 
destructive  action  of  the  pus  upon  the  delicate  structure  of  the  ear  is 
often  such  that,  within  a  few  days,  irreparable  harm  is  done  and  more 
or  less  deafness  results.  Relief  can  occur,  if  the  Eustachian  tube 
remain  closed,  only  by  perforation  of  the  membrane  and  the  discharge 
of  the  secretions  into  the  external  meatus.  When  this  takes  place  the 
inflammation  in  the  most  favorable  cases  gradually  abates,  the  aperture 
in  the  drum  closes,  and  the  integrity  of  the  auditory  apj)aratus  is  pre- 
served.    In  severe  cases  the  mastoid  cells  participating  in  the  inflam- 


COMPLICATIONS     AND    SEQUELAE.  229 

mation  become  filled  with  muco-pus  and  tender  to  the  touch,  and  often 
the  collateral  oedema  causes  tumefaction  and  narrowing  of  the  external 
ear,  which  subside  with  the  discharge  of  pus  from  the  tympanum. 

Unfortunately,  there  is  for  many  a  more  melancholy  history — a  more 
destructive  inflammation,  involving  permanent  impairment  or  total  loss 
of  hearing.  Tiiis  is  especially  apt  to  occur  in  strumous  or  feeble 
children.  All  grades  of  inflammation  and  destructive  action  occur  in 
diifei'ent  cases.  The  perforation  in  the  drum-membrane  m;iy  be  large 
or  the  membrane  may  be  completely  destroyed,  and  the  detached  ossicles 
escape  one  by  one  into  the  external  meatus,  and  in  a  few  instances, 
fortunately  rare,  this  occurs  in  both  ears,  producing  complete  and  per- 
manent deafness.  In  my  own  practice  this  has  never  occurred,  but  I 
have  met  one  or  two  a<lalts  Avho  were  totally  deaf  from  this  cause. 

The  mucous  membrane  which  lines  the  bony  wall  of  the  middle  ear 
has  the  function  of  the  periosteum,  and  therefore,  when  inflamed  and 
subjected  to  pressure,  is  liable  to  ulcerate.  As  in  other  parts  of  the 
skeleton  under  similar  conditions,  superficial  caries  or  necrosis  of  the 
underlying  bone  is  apt  to  occur.  The  carious  or  necrotic  process  may 
extend  to  the  mastoid  cells.  An  oflensive  otorrhcea,  continuing  for 
months  or  years,  indicates  the  persistence  of  this  pathological  state  of 
the  tympanum,  which  is  rendel"ed  so  obstinate  by  the  presence  of  dead 
bone.  A  moment's  survey  of  the  anatomical  relations  of  the  middle  ear 
shows  the  danger  to  which  these  patients  are  liable.  A  thin  bony 
septum,  perforated  with  bloodvessels  and  sometimes  containing  con- 
genital apertures,  separates  the  tympanum  from'  the  cranial  cavity 
above.  Posteriorly  lie  the  mastoid  cells,  connected  with  the  tympanum 
by  one  large  and  several  small  apertures.  Anteriorly  is  the  commence- 
ment of  the  Eustachian  tube,  and  in  close  proximity  to  the  tympanum 
lies  the  carotid  c:uial,  and  at  one  point  also  the  superior  petrosal  sinus. 
A'irchow  has  sliown  how  inflannnation  extending  from  the  ear  in  otitis 
media  sometimes  produces  such  compression  of  the  veins  or  sinuses  by 
the  swelling  from  the  infiltration  and  exudation  that  the  circulation  is 
arrested,  and  the  fibrin  contained  in  the  blood  of  these  vessels  is  pre- 
cipitated, forming  tlirombi,  v.ith  the  most  disastrous  effect  upon  the 
individual.  Pus  may  also  burrow  in  the  interstices  of  the  bone,  causing 
great  i)ain,  or  the  pent-up  secretions,  having  no  outlet  for  escape,  may 
in  time  undergo  caseous  degeneration,  producing  the  conditions  in  which 
tuberculosis  so  often  originates. 

Death  not  infrequently  occurs  in  chronic  otitis  media  in  another  way. 
The  otorrhica,  ;ifter  months  or  years,  suddenly  ceases,  the  child  com- 
plains of  constant  severe  headache  and  is  feverish,  an<l  the  case  ends  in 
coma,  preceded  perhaps  by  convulsions.  Meningitis  has  occurred,  pro- 
duced by  extension  of  the  inflammation  through  the  thin  bony  septum 
which  divides  the  tympanum  from  the  cranial  cavity,  and  at  the  autopsy 
hypenumia  of  the  meninges,  fibrin,  pus,  perhaps  softening  of  the  brain 
aiul  an  abscess,  are  found  in  the  portion  of  the  encephalon  adjacent  to 
the  tynipaiuim.  Therefore,  otitis  media,  though  it  often  ends  favorably, 
is  in  many  patients  an  obstinate,  dangerous,  and  evt'u  fatal  s('(piel  of 
scarlet  lever. 

The  complication  known  as  scarlatinous  rheumatism  is  regarded  by 


230  SCARLET    FEVER. 

some  as  a  sjno-VMtis,  but  its  symptoms,  especially  its  shifting  from  joint 
to  joint,  seem  to  ally  it  to  the  rlieumatic  affections.  In  some  epi- 
demics it  is  common.  It  usually  begins  toward  the  close  of  the  first 
week  or  in  the  second  week,  and  its  common  seat  is  in  the  ankle,  pha- 
langeal, and  wrist  joints.  It  is  attended  by  very  little  swelling  in  most 
patients,  though  the  joints  are  tender  and  painful  on  pressure.  It  does 
not  seem  to  retard  convalescence  materially,  but  it  produces  suffering 
and  involves  danger  as  regards  the  heart.  It  subsides  in  a  few  days 
with  the  ordinary  treatment  of  acute  rheumatism,  and  even  without 
special  treatment,  the  chief  danger  being  that,  as  in  idiopathic  rheuma- 
tism, endocarditis  may  arise,  with  permanent  crippling  of  the  valves. 
The  following  was  a  case  of  valvular  disease  having  this  origin.  It 
occurred  in  my  practice. 

Case  5. — Freddy  M.,  aged  four  years,  sickened  with  scarlet  fever 
March  6,  1879.  The  usual  vomiting  occurred  on  the  first  day,  and  the 
temperature  was  104\  The  case  progressed  favorably  till  March  14, 
Avhen  he  cuin])lained  of  pain  in  both  wrists,  both  ankles,  and  both  knees. 
On  March  17th  the  general  condition  was  good,  the  urine  contained  no 
albumen,  and  apparently  few  urates,  but  he  still  had  pain  in  the  joints  of 
the  upper  and  lower  extremities  and  in  the  back  ;  pulse  140,  temperature 
103^ ;  breathes  with  a  slight  moan;  urates  in  the  urine,  but  no  albumen. 
A  distinct  mitral  regurgitant  murmur  is  now  heard  for  the  first  time. 
Under  the  use  of  salicylate  of  sodium  the  pain  in  the  joints  soon  ceased, 
but  the  mitral  murmur  is  permanent. 

The  following  prescription  is  for  a  child  of  five  years: 

R  _()1.  sraultheriie f^j;_ 

Sodii  Siilicylat .^iij. 

Syrupi f^ij- 

Aquaj f5iv.— Misce. 

Sig. — Give  one  teaspoonful  every  four  liours  in  water. 

Of  the  serous  inflammations  complicating  scarlet  fever,  pericarditis 
has  been,  according  to  Ililliet  and  Barthez,  most  frequently  observed. 
In  this  country  it  is  probably  more  common  than  is  usually  supposed, 
but  it  is  less  frequently  detected  than  pleuritis,  the  symptoms  of  which 
are  more  conspicuous. 

The  following  case,  which  occurred  in  my  practice,  Avas  an  exainjde  of 
this  conqjlication: 

Cash  6. — C ,  girl,  aged  five  years  and  ten  months,  sickened  with 

severe  scarlet  fever  on  Aprir4th.  Was  delirious;  pulse  158  ;  had  vomit- 
imr  and  constipation.  April  10th,  pulse  varies  from  124  to  153,  no 
delirium;  a  considerable  quantity  of  urates  in  the  urine.  April  11th, 
has  to-day,  for  the  first  time,  severe  pain  in  the  epigastrium,  with  tender- 
ness and  "moderate  distentivm.  Otherwise  synq)toms  favorabk>,  but  severe ; 
pulse  140;  respiration  moderately  accelerated,  and  vesicular  in  every 
part  of  the  chest.  From  this  date  the  synq)toms  continued  about  the 
same  till  Ai)ril  14th,  wiien  the  dyspntea  became  more  marked,  and  the 
action  of  tlie  lieart  rapid  and  tuimdtuous.  The  epigastric  ])ain,  disten- 
tion, and  tenderne-s  continued  ;  the  pennission  s')und  was  dull  over  the 
lower  part  of  the  chest;  the  dysimrea  became  rapidly  worse,  althouijjh  the 
pulse  had  considerable  volume ;  and  at  5  p.  m.  death  occurred.     At  the 


COMPLICATIONS    AXD    SEQUELJE.  231 

autopsy  about  one  ounce  of  turbid  serum,  with  a  soft  deposit  of  fibrin, 
was  found  in  the  pericardium.  P2ach  pleural  cavity  contained  from  six 
to  eight  ounces  of  transparent  serum,  and  both  lungs  were  readily  inflated, 
except  a  little  of  the  posterior  portions  of  both  lower  lobes;  no  fibrinous 
exudation  over  the  lungs.  The  liver  extended  four  inches  below  the 
margin  of  the  ribs,  and  upon  its  convex  surface  in  the  epigastrium,  corre- 
si)iinding  with  the  seat  of  the  pain,  was  a  rough  patch  of  fibrin  about  one 
ami  a  half  inches  in  diameter.  The  bronchial  mucous  membrane  was 
moderately  injected,  as  was  also  that  of  the  colon,  and  the  kidneys  appeared 
hyperiemic. 

Among  tlie  serous  inflammations  which  complicate  or  follow  scarlet 
fever,  pjeuritis  is  one  of  the  most  important.  It  usually  begins  in  the 
desquamative  stage,  and  is  frequently  suppurative  on  account  of  the 
feeble  state  of  the  patient  when  it  commences.  It  has,  in  my  practice, 
been  tedious,  as  all  empyemas  are,  and  it  does  not  differ  in  its  clinical 
history  from  the  idiopathic  disease.  I  have  met  cases  of  scarlatinous 
emj)yema  in  which,  from  opposition  of  the  family  or  for  other  reasons, 
thoracentesis  was  not  performed,  and  death  occurred;  others  in  which 
this  operation  effected  a  cure,  and  one  at  least  in  which  the  patient 
recovered  by  escape  of  pus  through  a  bronchial  tube  and  its  expectora- 
tion. The  pleuritis  is  seldom  latent,  or  so  masked  by  the  symptoms  of 
the  general  disease  that  it  is  liable  to  be  overlooked.  On  the  other 
han(l,  the  cough,  embarrassment  of  respiration,  and  pain  referred  to  the 
affected  side  render  diagnosis  easy. 

Diltftation  of  the  heart  is  common  in  grave  cases  of  scarlet  fever, 
such  cases  as  are  properly  termeil  malignant.  It  is  indicated  by  a  feeble 
and  quick  pulse.  Acute  infectious  maladies,  especially  those  of  a 
malignant  type  and  acctjmpanied  by  high  febrile  movement,  are  very 
liable  to  cause  parenchymatous  degenerations  in  organs,  prominent  among 
which  is  granulo-fatty  degeneration  of  the  muscular  fibres  of  the  heart. 
This  weakens  very  much  the  contractile  power  of  these  fibres.  But 
early  in  malignant  cases,  probably  before  the  muscular  fibres  are 
damaged,  the  contractile  power  of  the  heart  is  feeble  from  impaired 
innervation,  the  residt  of  the  general  weakness.  Hence  this  organ, 
when  weakened  by  structural  change  an<l  insulficiently  stimulated  through 
diminished  innervation,  may  not  fully  empty  itself  during  the  systole, 
and  consecjucntly  it  becomes  dilatetl.  Dilatatitm  of  the  heart  and  im- 
perfect contraction  of  its  auricular  and  ventricular  walls  facilitate  the 
formation  of  clots  in  the  cavities  of  the  heart;  and  this  ap])ears  to  be 
the  immediate  cause  of  death  in  not  a  few  instances.  An  ante-mortem 
clot  occurring  in  any  of  the  cavities  of  the  heart  necessarily  seriously 
obstructs  the  circulation,  uidess  it  be  of  small  size.  Hence  the  dys- 
pnoea, which  may  occur  suddenly,  and  the  change  of  pulse  to  one  of 
marked  feebleness  and  freipiency.  Large,  firm  white  clots  are  most 
freijuently  found  in  the  right  cavities.  They  interlace  with  the  chonhe 
tendine:c,  lie  even  within  the  auriculo-ventricidar  opening,  and  send 
prolongations  into  the  pidmonary  artery  and  the  cavju.  Associated 
with  the  white  clots  are  dark,  soft  clots  and  fluid  blood.  The  left 
cavities  may  be  contracted  and  empty,  or  they  may  contain  dark,  soft 
clots  or  white  ante-mortem  clots.      Clots  in  the  left  ventricle  are  .some- 


232  SCARLET    FEVER, 

times  prolonged  into  the  aorta  as  far  as  the  brachiocephalic  branches, 
while  tlio.se  in  the  left  auricle  may  extend  to  the  pulmonary  veins. 
If  dilatation  of  the  heart  be  so  great  that  clots  form  in  its  cavities, 
speedy  death  is  probable.  Sometimes  a  ])atient  passes  through  scarlet 
fever  and  appears  in  a  fair  way  to  recover,  when  he  succumbs  to  some 
exhausting  sequel  distinct  from  the  heart,  and  at  the  autopsy  the  heart 
is  found  ddated  and  containing  whitish  clots,  which  are  probably  ante- 
mortem,  and  which  hastened  death  by  obstructing  the  circulation.  Un- 
der such  circumstances  this  state  of  the  heart  is  attributable  in  irreat 
measure  to  the  complication  which  has  weakened  its  contractile  power. 

The  following  was  a  case  in  point.  It  occurred  in  the  New  York 
Foundling  Asylum : 

Cask  7. — R.  A.,  aged  three  years,  had  scarlet  fever,  beginning  [March 
23,  18S2.  Tlie  symptoms  were  favorable  at  Hrst,  but  serious  complications 
and  sequelae  occurred,  which  were  fatal.  The  record  of  April  18th  reads  : 
•'Appears  well  nourished,  but  is  aniemic ;  has  otorrha^a ;  no  (edema; 
skin  desquamating;  duhiess  on  percussion  over  upper  third  of  right  s^ide 
of  chest,  anteriorly  and  posteriorly;  mucous  rales  and  rude  breathing 
over  same  area  ;  fine  rales  posteriorly  over  lower  part  of  left  side  of  chest  ; 
pulse  IGO,  respiration  68,  temp.  101|-^."  April  2()th.  is  feeble  and  takes 
nutriment  with  difficulty;  tongue  thickly  coated;  pulse  160,  respiration 
68,  temp.  lOlf^.  April  26th,  condition  about  the  same  as  at  last  record, 
but  he  is  evidently  weaker  ;  the  lips  are  ulcerated  and  fauces  still  swollen. 
May  2d,  cannot  speak  distinctly ;  a  brownish,  foul-smelling  secretion 
lodges  on  the  spoon  used  in  depressing  the  tongue ;  left  side  of  face 
swollen.  On  the  following  night  eight  convulsions  occurred,  attended  by 
orthopnrea,  and  mucous  rales  in  the  chest  from  y)ulmonary  (edema. 
Diarrh(£a  supervened  and  the  patient  died  about  midniuht. 

Autopsy:  Body  moderately  wasted  and  very  white,  several  dark  blue 
spots  on  scalp  and  face  from  hemorrhages  underneath.  A  careful  examina- 
tion showed  the  presence  of  brfmeho-jmeumonia  in  each  lung,  with  consid- 
erable infiltration  of  the  walls  of  the  bnmchi,  and  cylindrical  dilatati<m  of 
many  of  them  ;  cavitiesof  the  heart  dilated,  so  that  this  ortran  appears  much 
enlarged,  and  its  shape  appnjaches  the  globular;  its  apex  is  rounded  or 
obtuse ;  transverse  diameter  of  the  right  ventricle,  when  its  walls  were 
open  and  drawn  apart,  was  three  and  one-(|uarter  inches  ;  that  of  the  left 
ventricle  three  and  a  half  inches.  Similar  measurements  of  the  heart  of 
another  child  of  about  the  same  age,  believed  to  be  normal,  were  about 
one  inch  less  in  t;ach  direction.  All  the  caviti(,'s  contain  white  firm  clots 
along  with  soft  dark  clots.  Lesions  observed  in  other  organs  were  care- 
fully noted,  some  (jf  which  were  serious  ;  but  the  immediate  cause  of  death 
appeared  to  be  imperfect  contracticm  of  the  heart,  and  the  fornuition  of 
clots  in  its  cavities. 

There  can  be  little  doubt  that  nephritis  in  its  milder  form  is  much 
more  common  than  was  formerly  supposed.  A  few  years  since  little 
attention  was  given  by  a  large  proportion  of  physicians  to  the  state  of 
the  kidneys,  and  the  urine  was  not  examineil  till  dropsy  made  its  ap- 
pearance, which  only  occurs  in  the  more  severe  forms  of  ne])iiritis  and 
is  a  late  symptom.  It  is  now  known  that  catarrh  of  the  renal  tubes  fre- 
quentlv  occurs  in  a  mild  form  early  in  scarlet  fever,  without  causing 
albuminuria,  dropsy,  or  any  notable  symptom.     It  may  produce  a  smoky 


COMPLICATIOXS    AXU    SEQUEL.E.  233 

color  of  the  urine,  and  the  appearance  in  it  of  granuhu'  ejiithelial  cells, 
with  an  increase  of  mucus,  but  no  albumen.  With  careiul  treatment 
and  no  exposure  to  cold,  the  renal  catarrh  abates  with  the  decline  of  the 
scarlet  fever.  It  is  scarcely  severe  enough  to  merit  the  name  desquama- 
tive, tubal,  or  parenchymatous  nephritis,  though  it  is  a  mild  form  of  the 
3.ime  pathological  state.  Steiner  states,  as  the  result  of  many  careful 
examinations  of  cases,  that  hypersemia  of  the  kidneys  was  always  pre- 
sent in  those  Avho  died  early  in  scarlet  fever,  and  that  in  a  certain  pro- 
portion of  tliese  cases  catarrh  of  the  renal  tubules  Avas  present  in 
addition  to  the  congestion.  Even  in  some  who  died  on  the  second  or 
third  day  he  found  cloudiness  of  the  epithelium  in  the  renal  tubes, 
although  the  urine  had  not  indicated  such  a  change.  The  opinion  has 
even  been  expressed  that  catarrh  of  the  renal  tubes  is  as  common  in 
scarlet  fever  as  that  of  the  bronchial  tubes  in  measles ;  that  is,  it  is  a 
uniform  element  in  the  disease :  but  this  appears  to  be  an  exaggerated 
statement,  for  others  have  failed  to  find  any  evidence  of  renal  catarrh 
in  certain  cases. 

The  nephritis  which  gives  rise  to  symptoms  and  therefore  interests 
the  practitioner,  commonly  begins  in  the  declining  pei'iocl  of  scarlet 
fever  or  during  the  desquamative  stage,  and  is  in  many  instances  plainly 
attributable  to  exposure  to  cold  or  to  currents  of  air.  It  originates 
either  during  this  period,  ofTfTt  have  ])reviously  existed  as  a  mihl  renal 
catarrh,  it  now  becomes  aggravated.  Dropsy,  which  always  attracts  at- 
tention, does  not  occur  till  the  nephritis  has  continued  for  some  time. 

Why  nephritis,  Avith  the  subsequent  dropsy,  so  frequently  occurs  after 
scarlet  fever  is  not  fully  understood.  Rilliet  and  Barthez  attribute  it 
to  disturbance  of  the  function  of  the  skin.  The  fact  has  long  been 
observed  that  tlu;  kidneys  become  atfected  nearly  if  not  (piite  as  fre- 
quently after  mild  as  severe  cases.  Indeed,  the  chief  danger  in  mild 
caries,  when  the  patients  are  but  a  short  time  in  bed  and  are  soon  allowed 
to  go  about,  is  from  the  nepliritis.  Clnlling  the  surface  and  checking 
cutaneoiis  transpiration  appear  to  be  the  inunediate  cause  of  this  inflam- 
mation  in  a  consi<lerable  proportion  of  cases.  Tlierefore,  severe  attacks  of 
scarlet  fever  with  abundant  rash  and  des(piauiation,  whicli  reijuire  the 
patient  to  be  kept  in  bed  the  proper  time  aii<i  in  a  warm  ro(jui  two  or 
three  weeks,  appear  to  be  less  frequently  followed  by  this  renal  disease 
than  are  milder  cases  which  are  more  carelessly  treated, 

Tbe  most  thorough  and  minute  microscopic  examinations  of  the  state 
of  the  kidneys  in  scarlet  fever  which  have  come  to  mv  notice  were 
those  by  E.  Klein,  published  in  the  Loiid.  Path.  Soc.  Tnots.,  and  illus- 
trated by  microscopic  drawings.  It  appears  from  these  examinations 
that  the  changes  in  the  kidneys  are  complex,  among  whicii  we  recognize 
both  those  of  parenchymatous  or  des({uauiative  ne])hritis  and  interstitial 
nephritis:  but  we  would  infer  that  the  interstitial  nephritis  is  mild  in 
degree  and  quite  subordinate,  or  else  confiiu'd  to  ])ortions  of  the  organ, 
from  the  fact  that  so  many  permanently  and  fully  recover.  The  follow- 
ing is  a  resume  of  Kleins  examinations  in  twenty-three  cases:  We  con- 
clude from  these  microscopic  researches  that  the  anatomical  changes  of 
both  parenchymatous  and  interstitial  nephritis  are  commonly  jirescnt  in 
greater  or  less  degree  in  cases  of  scarlet  fever.     If  they  are  mild  or  con- 


234  SCARLET    FEVER. 

fined  to  portions  of  the  kidneys,  no  symptoms  occur;  but  if  they  are 
sufficient  in  extent  or  degree  to  impair  the  function  of  these  organs,  then 
symptoms,  as  albuminuria,  diminution  of  urine,  etc.,  appear. 

1.  J^arenchi/DuUoHS  NepltritiH,  Proliferation  of  Nuclei,  Hyaline  De- 
generation of  Arterioles.  The  Glomerulo-nephritis  of  Klehs. — Klein 
found  increase  of  nuclei  (probably  epithelial)  upon  the  glomeruli  and 
hyaline  degeneration  of  the  intima  of  minute  arteries,  especially  marked 
in  the  afferent  arterioles  of  the  Mal|)ighian  bodies.  The  intima  of  these 
vessels  was  in  places  so  swollen  as  to  resem1)le  cylindrical  or  spindle- 
shaped  hyaline  masses,  and  cause  narrowing  of  the  lumina  of  the  vessels 
in  which  this  degeneration  occurred.  Klein  observed  in  some  specimens 
so  great  hyaline  degeneration  of  the  capillaries  of  the  Malpighian  bodies 
that  circulation  through  them  was  obstructed.  In  the  more  advanced  or 
protracted  cases  this  hyaline  substance  in  the  glomeruli  began  to  assume 
a  fibrous  appearance.  Bowman's  capsule  was  considerably  thickened. 
This  hyaline  degeneration  of  the  Malpighian  bodies  Klein  discovered  in 
the  earliest  cases  which  fell  under  his  observation. 

Also  in  the  earliest  cases  the  multiplication  or  germination  of  the 
nuclei  of  the  muscular  coat  of  the  arterioles  was  observed,  with  a  corre- 
sponding increase  in  the  thickness  of  the  walls  of  these  vessels.  This 
change  in  the  muscular  element  was  found  in  the  arterioles  in  different 
parts  of  the  kidney,  but  it  Avas  most  conspicuous  in  these  vessels  at  their 
point  of  entrance  into  the  Malpighian  bodies;  and  it  was  distinctly  no- 
ticed in  other  arterioles,  both  in  the  cortex  and  in  the  base  of  the 
pyramids. 

In  the  glandular  portion  of  the  kidneys  other  anatomical  alterations 
were  observed,  indicating  parenchymatous  nephritis.  There  were  swell- 
ing of  the  epithelial  lining  of  the  convoluted  tubes;  multiplication  of 
nuclei  of  epithelial  cells  especially  in  ascending  tubules,  which  lay  close 
to  the  afferent  arterioles  of  Malpighian  corpuscles;  granular  matter,  and 
even  blood,  in  the  cavity  of  Bowman's  capsule  and  in  the  convoluted 
tubes;  cloudy  swelling  and  gi-anular  disintegration  of  epithelium  in 
some  parts  of  the  convoluted  tubes;  detachment  of  epithelium  from  the 
membrane  of  larger  ducts  of  the  pyramids  in  some  cases.  These 
parenchymatous  changes  are  already  known  to  the  profession  through 
the  observations  and  writings  of  Dickinson,  Fenwick,  Johnson,  John 
Simon,  and  others. 

Klein,  in  commenting  on  the  hyaline  degeneration  which  he  observed, 
states  that  Neelsen  found  the  walls  of  the  capillaries  of  the  pia  mater 
thickened,  highly  refractive,  and  of  a  lardaceous  appearance  in  certain 
acute  infectious  maladies,  as  variola,  typhoid  fever,  measles,  and  in  one 
case  of  scarlet  fever.^  Usually,  only  a  small  portion  of  the  capillaries 
were  thus  affected,  most  frequently  at  the  point  of  division  into  branch- 
lets.  In  a  few  instances  Neelsen  noticed  degenei-ation  of  arterioles 
extending  a  considerable  distance,  with  fusion  of  the  intima,  media,  and 
adventitia,  and  chemical  examination  showed  that  the  substance  pro- 
duced by  this  degeneration  had  similar  properties  to  elastic  tissue. 
Although  the  examinations  by  Neelsen  relate  to  the  pia  mater,  two  of 

^  Archiv  der  Ueilkunde,  1876. 


COMPLICATIOXS    AXD    SEQUEL.E.  235 

his  observations  are  especially  interesting — first,  that  the  hyaline  change 
alTects  chiefly  vessels  near  their  point  of  branching;  and,  secondly,  that 
the  hyaline  substance  is  of  the  nature  of  elastic  tissue,  for  in  the  kidne}? 
in  scarlatinous  nephritis  the  arterioles  undergo  the  change  in  question 
chiefly  near  their  point  of  branching  into  the  capillaries  of  the  glome- 
rulus ;  and  the  intima  being  the  part  wbich  undergoes  the  hyaline 
change,  it  is  probable,  in  the  opinion  of  Klein,  that  the  same  substance 
is  produced  by  the  degeneration  in  walls  of  the  vessels  of  the  kidney 
which  Neelsen  observed  in  the  pia  mater,  and  therefore  that  it  is  of  the 
nature  of  elastic  tissue. 

This  hyaline  degeneration  of  the  arterioles  is  also  very  marked  in  the 
spleen  in  scarlet  fever;  and  in  studying  the  minute  anatomy  of  the 
intestines  and  spleen  in  typhoid  fever,  Klein  has  found  the  same  degen- 
eration of  the  intima  of  the  minute  vessels.  He  believes  that  this 
hyaline  change  and  the  proliferation  of  muscle-nuclei  which  thus  occur 
at  an  early  period  in  scarlet  fever  in  the  renal  vessels  when  the  kidneys 
become  affected  are  due  to  an  irritatino-  cause  acting  similarly  to  that  in 
typhoid  fever. 

Klein  calls  attention  to  the  interesting  examinations  of  the  scarlatinous 
kidney  made  by  Klebs,  who  attributed  the  diminished  urination  and  the 
uriemic  poisoning  in  certain  cases  in  which  the  kidneys  do  not  exhibit 
any  marked  change  to  the  naked  eye,  to  what  he  designates  glomerulo- 
nephritis. Klebs  says:  "  In  tiie  post-mortem  examination  the  kidneys 
are  found  slightly  or  not  at  all  enlarged,  firm,  .  .  .  the  parenchyma 
very  hypenemic.  Only  the  glomeruli  appear,  on  close  inspection,  pale 
like  small  white  dots.  The  urinary  tubes  are  often  not  changed  at  all. 
Occasionally  the  convoluted  tubes  are  slightly  cloudy.  The  microscopic 
examination  shows  that  there  are  neither  interstitial  changes  nor  pro- 
liferation of  epithelium,  the  so-called  renal  catarrh  generally  supposed 
to  be  present  in  these  conditions  on  account  of  the  absence  of  other 
perceptiljle  derangements;  and  there  seems,  therefore,  leaving  out  the 
glomeruli,  the  congestion  of  the  kidneys  alone  to  remain  to  account  for 
the  symptoms  during  life."  But  that  mere  congestion  is  insufficient  to 
produce  the  symptoms  appears  from  the  fact  that  it  does  not  cause 
them  under  other  circumstances.  Klebs  finds,  '"on  microscoj)ic  exam- 
ination of  the  glomerulus,  the  whole  R|)ace  of  tiie  capsule  filled  with 
snuill  somewhat  angular  nuclei,  embedded  in  a  finely  granular  mass. 
The  vessels  of  the  glomerulus  are  almost  completely  covered  by  nuclear 
masses." 

Klein,  commenting  on  these  examinations  by  Klebs,  states  that  in  all 
early  cases  which  he  examined  he  observed  great  abundance  of  nuclei 
of  the  glomeruli,  but  a  c(Midition  like  that  described  and  figiirtMl  by 
Klebs'  he  has  seen  in  only  a  few  glomeruli ;  for  a  general  state  of  these 
bodies,  as  described  by  this  observer,  and  such  an  excessive  ))roliferati(m 
of  the  nuclei  that  the  bloodvessels  are  com|)letely  com|)resse(l,  was  not 
seen  in  one  of  the  twenly-thrce  cases.  Klein  therefore  tjuestions 
whether  the  diminished  urination  and  retention  of  urea  in  scarlet  fever, 
when  the  kidneys  do  not  exhibit  any  conspicuous  catarrhal  or  other 

1  llundl.ucli  dcr  Pulhol  ,  ]..  (;4*;,  fig.  7U. 


236  SCARLET    FEVER. 

change,  is  due,  unless  in  exceptional  instances,  to  compression  of  the 
vessels  of  the  glomeruli  by  nuclear  germination,  but  believes,  rather, 
that  the  obstructed  circulation,  and  consequent  diminished  ui'inary 
excretion,  is  largely  due  to  the  changed  state  of  the  arterioles.  Klein 
adds  that  perhaps  undue  contraction  of  the  arterioles,  through  stimula- 
tion by  the  blood-irritant,  may  also  be  a  factor  in  causing  arrest  of  cir- 
culation in  the  Malpighian  corpuscles.  As  regards  cases  that  perished 
early,  he  found  the  parenchymatous  change  slight,  so  that  a  careful 
examination  was  required  in  order  to  detect  cloudy  swelling  and  gran- 
ular degeneration. 

2.  Interstitial  Nepliritis. — A  second  set  of  changes  Klein  observed 
in  cases  that  died  about  the  ninth  or  tenth  day.  In  such  cases  he 
found  changes  due  to  interstitial,  in  addition  to  those  produced  by  paren- 
chymatous, nephritis.  Round  cells,  lymphoid  cells,  or  whatever  else 
they  should  be  called,  were  seen  in  the  connective  tissue  of  the  kidneys. 
In  the  kidneys  of  those  that  died  at  the  end  of  the  first  week  after  the 
comniencement  of  nephritis,  infiltration  with  round  cells  was  observed 
in  tlie  connective  tissue  around  the  large  vascular  trunks.  At  a  later 
stage  this  infiltration  had  extended  into  the  bases  of  the  pyramids  and 
into  the  cortex.  The  gradual  increase  in  extent  and  intensity  of  this 
infiltration  was  so  decided  in  the  cases  which  Klein  observed,  that  he 
has  no  hesitation  in  concluding  that  wlieu  interstitial  nephritis  occurs  it 
begins  about  the  end  of  the  first  week,  in  the  manner  already  stated — 
to  wit,  as  a  slight  infiltration  of  the  tissues  around  the  large  vascular 
trunks,  and  gradually  extends,  so  that  portions  of  the  cortex,  and  rarely 
portions  of  the  base  of  the  pyramids,  are  changed  into  firm,  pale,  round- 
cell  tissue,  in  which  the  original  tubes  of  the  cortex  become  lost. 

The  inHltratiou  of  the  cortex  with  round  cells,  beginning  at  the  roots 
of  the  interlobular  vessels,  spreads  rapidly  toward  the  capsule  of  the 
kidney,  and  laterally  among  the  convoluted  tube?  around  the  Malpighian 
bodies.  ...  In  the  course  of  this  process  considerable  parts  of  the 
peripheral  cortex,  occasionally  of  a  cuneiform  shape,  with  the  base 
nearest  the  capsule  of  the  kidney,  become  changed  into  Avhitish,  firm, 
bloodless,  cellular  masses,  in  which  Malpighian  corpuscles  and  urinary 
tubes  are  only  imperfectly  recognized,  being  more  or  less  degenerated. 
In  some  cases  attended  by  this  infiltration  of  the  cortex,  Klein  observed 
a  more  or  less  dense  reticulation  of  fibres,  especially  around  the  inter- 
lobular arteries,  containing  in  its  meshes  lymph-cells,  chiefly  uninuclear. 

In  a  child  of  five  years  that  died  after  a  sickness  of  tliirteen  days, 
Klein  found  evidence  of  intense  interstitial  inflammation,  and  also 
emboli,  consisting  of  fibrin  with  a  few  cells,  in  the  arteries,  both  in 
those  of  large  size  and  in  the  arterioles,  chiefly  where  they  enter  the 
Malpighian  corpuscles.  He  states  that  in  the  specimens  which  he  ex- 
amined the  more  intense  the  degree  of  interstitial  change,  the  greater 
was  the  enlargement  of  the  kidneys,  and  the  more  distinct  also  were  the 
evidences  of  parenchymatous  nephritis  in  the  urinary  tubes,  which 
either  contained  casts  or  were  in  process  of  destruction.  By  being 
crowded  with  inflammatory  products,  especially  cells,  the  Malpighian 
corpuscles  Avere  obliterated,  undergoing  fibrous  degeneration.  A  very 
curious  fact  observed  was  the  deposit  of  lime  in  the  urinary  tubes,  first 


COMPLICATIONS    AND    SEQUEL.E.  237 

of  the  cortex,  and  then  also  of  the  p^'ramids,  at  an  early  stage  of  scarlet 
fever,  Avhen  the  kidneys  otherwise  showed  only  slight  change.  Several 
observers,  as  Biermer,  Coats,  and  AVagner,  have  each  described  a  case 
of  scarlet  fever  with  interstitial  nephritis,  which  they  consider  unusual; 
but  Klein  has  apparently  demonstrated,  as  we  have  seen,  by  a  large 
number  of  microscopic  examinations,  that  this  form  of  nephritis  is 
common  after  the  ninth  or  tenth  day. 

Nephritis,  in  proportion  to  its  extent  and  gravity,  is  accoinpanied  by 
lan^)r,  febrHejnovement,  thirst,  loss  of  appetite  and  strength.  At 
first  tTie  patient  experiences  but  slight  pain  in  the  head  or  elsewhere 
and  the  quantity  of  urine  is  not  notaljTy  climinished  ;  but  as  the  disease 
continues  urination  becomes  less  frequent  and  the  urine  more  scanty. 
Albuminuria  occurs,  while  the  uresi  is  only  partially  excreted,  and 
therefore  it  accumulates  in  the  blood.  If  the  nephritis  be  so  severe  or 
protracted  that  this  principle  accumulates  to  a  certain  extent,  grave 
symptoms  occur,  as  headache,  vomiting,  apathy  or  restlessness,  and, 
more  dangerous  than  all,  eclampsia,  which  js  not  unusual  in  these 
cases.  Microscopic  examination  of  the  urine  shows  the  presence  in 
this  liquid  of  blood-corpuscles,  gramijar^epithelial  cells,  and  hyjiline  or 
granular  casts,  or  both.  The  specific  g.ravity  of  the  urine  is  dimhiished. 
But  a  lai'ge  quaiitity  of  albumen  in  the  urine  may  render  the  specific 
gravity  as  liish  or  hiirher  than  in  health. 

Tbe  altered  state  of  the  blood  soon  gives  rise  to  transudation  of 
sejinn,  first  observed  in  most  cases  as  an  anasarca  occurring  in  the  feet 
and  ankles.  The  oedema,  if  not  checked  by  treatment  or  through  mild- 
ness of  tbe  disease,  extemls  over  the  limbs,  scrotum,  and  sometimes 
upon  tbe  trunk.  It  is  well  if  the  dropsy  remain  limited  to  the  subcu- 
taneous connective  tissue,  but  unfortunately,  it  is  apt  to  occur,  if  the 
nephritis  continue,  in  and  around  the  internal  organs,  producing,  men- 
tioned in  the  order  of  frequency,  pulmonary  oedema,  effusion  into  the 
pleural  and  peritoneal  cavities,  the  pericardium,  the  encejjhalon,  and 
lastly^  into  the  connective  tissue  of  the  larynx,  causing  that  very  fatal 
comi)lication,  oedema  of  the  glottis.  Although  this  is  the  common 
order  in  wliich  dropsies  occur,  exceptions  are  not  infrequent.  Even 
the  anasarca  may  not  be  the  first  to  appear,  although  in  the  vast 
mnjority  of  cases  it  has  the  precedence.  Thus,  Rilliet  relates  the  case 
of  a  boy  of  five  years  who  twenty  days  after  tbe  occurrence  of  scarlet 
fever,  and  six  hours  after  the  appeai'ance  of  bloody  and  albuminous 
urine,  had  double  hydrothorax,  rapidly  developed.  As  long  as  the 
hydrothorax  continued  no  anasarca  was  observed,  but  as  it  declined 
anasarca  a])peared.  Legendre  cites  a  case  in  which  oedema  of  the 
lungs  occurred  without  anasarca  or  other  dropsy.  Occasionally,  the 
anasarca  and  internal  dropsies  take  place  nearly  simultaneously.  The 
nephritis  and  consequent  serous  effusions  usuiilly  appear  witliinjhree 
weeks  after  scarlet  fever  ends,  but  cases  occur  in  which  tbe  cITusions  are 
first  observed  as  late  as  the  fourth  and  fifth  weeks.  Tbe  patient  may 
bo  considered  to  possess  immunity  from  this  sequel  if  be  have  reaejied 
the  close  of  the  fifth  week  after  the  abatement  of  scarlet  fever  without 
its  occurrence. 

The  dropsy  is  usually  acute,  but  it  may  assume  the  chronic  form, 


238  SCARLET    FEVEH. 

since  the  nephritis  which  causes  it,  happily  curable  in  most  instances, 
may,  if  neglected,  become  chronic.  Whether  the  dropsy  in  itself 
involve  danger  depends  in  great  part  on  its  location.  Anasarca  and 
ascites  may  exist  a  long  time  with  little  suflering  or  danger,  but  a  small 
amount  of  serum  in  certain  other  localities  causes  alarming  symptoms 
and  speedy  death.  (Edema  of  the  lungs,  hydro-pericardium,  oedema 
of  the  glottis,  and  intracranial  effusions  are  always  dangerous,  and  the 
last  two  are  sometimes  ftxtal  within  twenty-four  to  forty-eight  hours. 
OEdema  of  the  lungs  has  been  fatal  within  twelve  hours  from  the  appear- 
ance of  the  first  symptoms  of  obstructed  respiration. 

Cerebral^ symptoms  occurring  during  scarlatinous  nephritis  are  prob- 
ably sometimes  due  to  the  irritatin^^effect  of  the  retained  urea  on  the 
nervous  centre.  In  other  cases  tFe  cause  appears  to  be  cerebral  oedema 
or  compression  of  the  bi'ain  by  effusion  of  serum  within  the  ventricles 
and  upon  the  surfjice  of  the  brain.  Headaclie,  dull  or  severe,  dilata- 
thm  of  the  pupils  or  their  oscillation  in  a  uniform  light,  vomiting  with 
little  apparent  nausea,  are  common  symptoms  of  scarlatinous  nephritis 
when  it  has  continued  a  few  days,  and  the  excretion  of  urea  is  so 
diminished  that  tliis  substance  begins  to  exert  its  poisonous  effect  on 
the  system.  Such  symptoms  are  frequently  followed  by  somnolence, 
threatening  coma,  or  by  eclampsia,  unless  the  patients  are  promptly  and 
properly  treated.  In  some  patients  that  die  of  scarlatinous  nephritis, 
death  occurring  in  convulsions  or  coma,  no  appreciable  lesions  are 
observed  within  the  cranium,  unless  more  or  less  congestion,  the  fatal 
ending  being  attributable  to  the  ureemia.  In  other  instances  we  find 
an  effusion  of  serum  within  the  ventricles  or  upon  the  surface  of  the 
brain.  Although  the  symptoms  in  scarlatinous  nephritis  and  umemia 
may  appear  very  unfavorable,  the  prognosis  is  usually  good  under 
prompt  and  appropriate  treatment.  Thus  severe  convulsions  and  a 
degree  of  somnolence  that  bordered  on  coma  may  abate,  and  convales- 
cence be  fully  established  within  a  few  days.  Rilliet  and  Barthez 
announce  ten  recoveries  in  thirteen  patients  affected  with  convulsions 
due  to  this  renal  affection. 

Anatomical  Characters. — Scarlet  fever  being,  as  we  have  seen,  a 
constitutional  febrile  disease  of  an  ataxic  nature,  and  accompanied  by 
certain  inflammations,  necessarily  affects  the  composition  of  the  blood ; 
but  since  this  disease  varies  so  greatly  in  type  or  severity,  the  state  and 
appearance  of  this  liquid  also  vary.  At  the  autopsies  of  the  more 
malignant  cases  we  find  the  blood  dark  and  fluid,  with  small,  soft,  and 
dark  clots  in  the  heart  and  large  vessels.  In  other  cases  the  clots  are 
large,  firm,  and  solid,  as  described  in  a  preceding  page.  In  malignant 
cases  that  end  fatally  Rilliet  and  Barthez  state  that  both  the  large  and 
small  vessels  of  the  cerebral  meninges  and  the  brain  are  found  hyper- 
?emic.  but  in  a  variable  degree.  In  those  who  die  in  coma,  ])receded  by 
delirium  or  convulsions,  during  the  eruptive  stage,  the  intracranial  con- 
gestion is  usually  marked,  with  perhaps  some  transudation  of  serum,  but 
without  inflammatory  lesions.  The  fibrin  in  scarlet  fever  remains  in 
about  normal  proportion,  except  as  it  is  increased  by  inflammatory  com- 
plications. Andral  found  an  increase  in  the  proportion  of  blood-cor- 
puscles from  127  to  136  parts  in  1000. 


ANATOMICAL    CHARACTERS.  239 

The  respiratory  apparatus,  except  the  Schneiderian  membrane,  is 
usually  normal  when  no  complications  exist.  Samuel  Fenwick^  made 
post-mortem  examinations  in  sixteen  cases  of  scarlet  fever,  and  concludes 
from  them  that  inflammation  of  the  mucous  membrane  of  the  stomach 
and  intestines  occurs  like  that  of  the  skin,  followed  by  desquamation  of 
the  epithelial  cells,  like  that  of  the  epidermis.  1  have  had  the  oppor- 
tunity of  examining  the  stomach  and  intestines  of  those  who  died  of 
scarlet  fever  in  the  eruptive  stage,  and  have  not  found  any  unusual 
hypememia  of  the  gastro-intestinal  surface,  except  Avhen  gastro-intestinal 
inflammation,  usually  indicated  by  diarrhoea,  had  occurred  as  a  com- 
plication. 

In  some  cases  the  abdominal  organs  exhibit  changes  which  suggest  a 
resemblance  to  typhoid  fever.  The  spleen  is  enlarged  and  somewhat 
softened,  and  Peyer"s  patches  and  the  solitai-y  glands  are  thickened  and 
prominent,  but  less  in  degree  than  in  typhoid  fever.  The  mesenteric 
glands  also  are  in  a  state  of  hyperplasia.  In  other  patients  these  parts 
appear  normal. 

Klein  made  microscopic  examination  of  the  liver  in  eight  cases,  and 
states  that  he  found  granular  opaque  swelling  of  liver-cells,  and  changes 
in  the  internal  and  middle  coats  of  certain  arteries  similar  to  those 
observed  in  the  kidneys,  which  have  been  described  above.  He  also 
found  evidences  of  interstitial  inflammation,  as  an  increase  of  round 
cells  and  connective  tissue  in  the  liver.  lie  remarks  also  that  he 
observed  hyaline  degeneration  of  the  intima  of  arteries  in  the  spleen. 
Rilliet  and  Barthez  state  that  swelling  and  softening  of  the  spleen  are 
exceptional  in  scarlet  fever,  but  are  sufficiently  common  to  merit  atten- 
tion. In  post-mortem  examinations  which  I  have  witnessed  nothing 
noteworthy  has  appeared  to  the  naked  eye  in  the  state  of  the  liver,  nor 
ordinarily  in  that  of  the  spleen. 

The  efflorescence,  though  one  of  the  anatomical  characters,  has  per- 
haps been  sufficiently  described  in  the  foregoing  pages.  It  begins  over 
the  neck,  chest,  and  groins  as  numerous  reddish  points  not  larger  than 
a  pin's  head,  closely  crowded  together,  but  with  skin  of  normal  color 
between.  It  is  estimated  that  the  aggregate  efliorescence  and  aijjrresate 
normal  skin  over  a  given  area  are  about  equal.  If  the  cutaneous  circu- 
lation be  active  and  the  febrile  movement  be  considerable  these  spots 
extend  and  coalesce,  producing  an  efflorescence  like  erythema  or  like  the 
hue  of  a  boiled  lobster,  to  which  it  has  been  likened.  The  efflorescence, 
less  upon  the  face  than  upon  the  trunk,  contrasts  in  this  respect  with 
that  of  measles,  in  which  the  rash  is  fidl  in  the  face,  often  causing  some 
swelling  of  the  features.  It  is  also  less  upon  the  palmar  and  plantar 
surfaces  than  elsewhere.  It  scarcely  causes  any  perceptible  elevation 
of  the  skin,  but  in  certain  localities,  as  upon  the  backs  of  the  hands 
and  upon  the  forearms,  it  communicaws  the  sensation  of  slight  rough- 
ness. The  seat  of  the  efflorescence  is  mainly  in  the  superficial  layers 
of  the  skin,  but  it  is  said  that  it  sometimes  has  occurred  upon  a  cicatrix, 
as  that  from  a  Imrn.  In  the  robust  and  in  favorable  cases  in  which  the 
circulation  is  active  the  rash  has  a  scarlet  hue,  and  when  the  cutaneous 
capillaries  are  emptied,  and  the  skin  rendered  pale  by  pressure  with  the 

*  London  Luncct,  July  23,  181)4. 


2-iO  SCARLET    FEVER. 

fingers,  the  circulation  immediately  returns  when  the  pressure  is  removed. 
In  malignant  cases  the  color  is  not  scarlet,  but  dusky  red,  and  so  slug- 
gish is  the  capillary  circulation  that  the  skin  when  pressed  upon  recovers 
the  blood  very  slowly.  In  grave  cases  also  extravasation  of  blood  in 
minute  points  or  transudation  of  its  coloring  matter  is  apt  to  occur  in 
portions  of  the  surface,  Avhen,  of  course,  decolorization  is  not  fully  pro- 
duced by  pressure.  In  cases  ending  fatally,  during  the  eruptive  stage 
the  efflorescence  may  entirely  disappear  in  the  cadaver,  or  it  remains 
upon  parts  of  the  surface,  especially  depending  portions.  Desquamation 
is  attributable  to  the  exaggerated  proliferation  of  the  epidermis  and  the 
loosening  of  its  attachment  by  the  inflammation. 

DiAGXOSis. — In  the  commencement  of  scarlet  fever,  prior  to  the 
eruption,  no  symptoms  or  appearances  exist  which  enable  us  to  make  a 
positive  diagnosis.  Positive  statement  in  reference  to  the  nature  of  the 
attack  should  be  deferred,  for  the  credit  of  the  physician.  Still,  if  a 
child  with  no  appreciable  local  disease  sufficient  to  cause  the  symptoms 
a  few  days  after  exposure  to  scarlet  fever,  or  during  an  epidemic  of  this 
malady,  be  suddenly  seized  Avitii  fever,  the  pulse  rising  to  110,  120,  or 
more,  and  the  temperature  to  102°,  103°,  or  105°,  scarlatina  should  be 
suspected.  The  diagnosis  is  rendered  more  certain  at  this  early  stage 
if  vomiting  occur,  and  especially  if  the  fauces  be  red.  for  hypersemia  of 
the  fauces,  due  to  commencing  pharyngitis,  is  one  of  the  earliest  and 
most  constant  of  the  local  manifestations  of  scarlatina. 

When  the  eruption  has  appeared,  the  nature  of  the  malady  is  in  most 
instances  apparent.  The  punctate  character  of  the  eruption  before  it 
becomes  confluent,  its  occurrence  within  twenty-four  hours  after  the 
fever  begins  over  almost  the  entire  surface,  but  its  absence  or  scantiness 
upon  the  face,  and  especially  around  the  mouth,  serve  to  distinguish  it 
from  other  diseases. 

Scarlet  fever  and  measles  were  long  considered  identical  by  the  pro- 
fession, and,  though  the  ordinary  forms  of  these  maladies  can  be  readily 
distinguished  from  each  other,  cases  occur  in  which  the  differential  diag- 
nosis is  attended  by  some  difficulty.  But  there  are  differences  in  the 
symptoms  and  course  of  the  two  diseases  which  aid  in  discriminating 
one  from  the  other.  Measles  begins  with  marked  catarrhal  symptoms, 
as  if  from  a  severe  cold.  Mild  conjunctivitis,  causing  weak  and  Avatery 
eyes,  coryza,  and  mild  laryngo-bronchitis,  with  accompanying  cough, 
precede  the  eruption  three  or  four  days  and  continue  during  the  eruptive 
stage.  The  febrile  movement  in  the  prodromic  stage  of  measles  is 
remittent,  the  evening  temperature  being  two  or  three  degrees  higher 
than  that  in  the  morning.  Contrast  this  with  the  invasion  of  scarlet 
fever,  in  which  the  only  catarrh  is  that  of  the  buccal  and  faucial  sur- 
faces, and  there  is  consequently  little  or  no  cough,  and  the  febrile 
movement,  ordinarily  high  in.  the  beginning,  is  nearly  uniform  in  the 
different  hours  of  the  day.  The  scarlatinous  eruption  appears,  as  wo 
have  seen,  within  twelve  to  twenty-four  hours  about  the  neck  and  upper 
part  of  the  chest,  and  spreads  over  the  body  in  a  sliorter  time  than  that 
of  measles,  Avhich  appears  on  the  third  day.  The  rash  of  measles 
begins  to  fade  at  the  close  of  the  third  or  in  the  fourth  day  after  its 
appearance,  that  of  scarlet  fever  not  till  from  the  sixth  to  the  eighth 
day.     In  nearly  all  cases  of  measles,  even  when  the  rash  is  confluent 


DIAGNOSIS.  241 

upon  the  face  and  a  considerable  part  of  the  trunk,  in  consequence  of 
the  high  febrile  mov^ement  and  vigorous  cutaneous  circulation,  we  observe 
the  characteristic  rubeolar  eruption  upon  certain  parts  of  the  surfice, 
as  tiie  extremities,  which,  in  connection  with  the  history,  renders  diag- 
nosis certain. 

Erythema  resembles  the  scarlatinous  eruption,  but  its  duration  is 
commonly  shorter.  It  is  limited  to  a  part  of  the  surface,  and  it  is 
accompanied  by  much  less  febrile  movement.  The  temperature  in 
ervtbema  does  not  usually  rise  above  100°,  unless  for  a  few  hours, 
wliereas  in  scarlet  fever  it  continues  consideraldy  above  100°  for  several 
diiys.  The  scarlatinous  efflorescence  has  also  a  bi'ighter  red  or  more 
scarlet  hue  than  that  of  erythema,  except  in  the  more  malignant  cases, 
in  which  the  severity  of  the  symptoms  renders  the  diagnosis  clear. 
But  an  important  aid  in  differentiating  the  one  from  the  other  of  these 
diseases  is  the  fact  that  in  erythema  there  is,  with  few  exceptions,  no 
faucial  inflammation,  and  in  tlie  few  instances  in  which  it  is  present  it 
is  slight  and  transient,  fidincr  within  a  dav  or  two. 

Scarlet  fever  is  readily  diagnosticated  from  diphtheria,  although  the 
affinity  is  close  between  these  two  maladies.  The  early  appearance  of 
the  pseudo-membi'ane  upon  the  fauces  in  diphtheria,  its  absence  in 
scarlet  fever,  and  the  absence  of  any  appearance  resembling  it  until 
the  fever  has  continued  some  days,  and  the  characteristic  efflorescence 
uj)on  the  skin  in  scarlet  fever,  render  diagnosis  easy.  If  scarlet  fever 
have  continued  some  days  when  first  seen  by  the  physician,  the  diph- 
theritic pseudo-membrane  may  be  present  as  a  complication,  or  the 
fauces  may  present  an  appearance  like  diphtheria  from  ulceration  or 
sloughing  and  tlie  presence  of  foul  and  offensive  secretions,  which  pro- 
duce a  dark-grayish  and  fetid  mass  over  the  faucial  surface.  Under 
such  circumstances  the  character  of  the  disease  is  ascertained  by  the 
history  of  the  case,  and  especially  by  the  occurrence  of  the  scarlatinous 
eruption.  An  erythema  transient  and  limited  to  a  part  of  the  surface 
sometimes  appears  in  the  commencement  of  diphtheria,  and  at  a  later 
period,  as  a  result  of  the  toxjiamia,  upon  the  extremities.  Roseoloid 
points  and  patches  often  occur  up(tn  the  extremities.  Both  kinds  of  rash 
can  be  readily  diagnosticated  from  that  of  scarlet  fever,  for  the  erytliema, 
as  has  been  stated,  is  transient  and  partial,  and  does  not  exliibit  minute 
points  of  deeper  injection,  while  the  toxsemic  rash  differs  in  form  and 
aspect  from  that  of  scarlet  fever,  and  appears  at  a  stage  wiien  the  scarla- 
tinous efflorescence  has  faded  or  begun  to  fade. 

1'be  efflorescence  of  rothein  sometimes  closely  resembles  that  of 
sciirlet  fever,  though  it  is  usually  more  like  tliat  of  nu'asles  ;  but  it  is 
ordinarily  accompanied  by  symj)toms  which  are  much  milder  than  tliose 
of  scarlet  fever,  and  it  begins  to  al)ate  as  early  as  the  third,  and  dis- 
appears on  the  fourth  day.  Tlie  eyes  have  a  suffused  appearance,  the 
temperature  may  reach  102°  or  108°,  and  tlie  efflorescence  may  be  as 
general  over  the  body  as  that  of  scarlet  fever,  but  there  is  not  the  aspect 
of  serious  indisposition,  and  the  speedy  abatement  of  the  symptoms 
shows  that  the  disease  is  not  scarlet  fever. 

Prooxosis. — The  prognosis  depends  on  the  torm  of  scarlet  fever, 
whether  mild  or  severe,  the  strengrli  of  the  j)atient,  and  the  presence 

16 


242  SCARLET    FEVER. 

or  ahsonce  of  complications  or  sequels.  The  type  of  the  disease  la 
sometimes  so  mihl  throughout  an  epidemic  or  during  a  series  of  years 
that  death  seldom  occurs,  whatever  the  mode  of  treatment;  but  after- 
ward the  type  changes,  and  the  percentage  of  deaths  increases  and 
remains  high  till  another  mitigation  in  the  type  occurs. 

Sydenham,  in  the  middle  of  the  seventeenth  century,  stated  that 
scarlet  fever,  as  he  saw  it  in  London,  was  so  mild  that  it  scarcely 
deservo<l  the  name  of  disease :  "  Vix  nomen  morbi  merebatur."  Morton 
some  years  later,  and  Huxham  in  the  following  century,  had  abundant 
reason  to  regret  the  change  of  type,  and  now  throughout  Great  Britain 
scarlet  fever  is  one  of  the  most  fatal  and  most  dreaded  of  the  diseases 
of  childhood.  In  Dublin  during  the  present  century,  prior  to  1834, 
scarlet  fever  was  uniformly  mild,  so  that  on  one  occasion  of  eighty 
patients  in  an  institution  all  recovered.  In  1834  the  type  of  the  disease 
totally  changed  and  epidemics  of  unusual  virulence  occurred.  The  type 
frequently  changes  from  mild  to  severe  or  severe  to  mild,  not  only  in 
consecutive  years,  but  in  consecutive  months.  A  feAV  years  since  a  dis- 
tinguished physician  o£  New  York  treated  about  fifty  cases  of  scarlet 
fever  in  one  of  the  institutions  without  a  single  death,  but  a  few  months 
later  the  type  of  the  malady  changed,  and  his  OAvn  son  was  among  those 
who  perished  from  it.  The  prevailing  type  of  the  disease  should  there- 
fore be  considered  in  giving  the  prognosis  when  in  the  commencement 
of  a  case  we  are  asked  the  probability  as  regards  the  termination. 

Extensive  statistics,  including  those  collected  by  Murchison  from 
various  sources,  shoAV  that  in  difterent  epidemics  the  mortality  may 
vary  as  much  as  from  3  per  cent.  (Eulenberg,  of  Coblentz)  to  19.3  per 
cent,  (cases  seen  by  myself  in  New  York  City  in  1881-82,  many  of 
w^hich  were  complicated  by  diphtheria),  or  even  to  34  per  cent,  (epi- 
demic in  the  Palatinate  in  1868-89).  The  hospital  statistics  of  Ililliet 
and  Barthez  gave  46  deaths  in  87  cases,  or  about  53  per  cent. 

Observations  have  thus  far  failed  to  establish  any  connection  in  the 
atmospheric  conditions  of  temperature  or  moisture  and  the  type  of 
scarlet  fever.  Grave  as  well  as  mild  epidemics  have  occurred  in  all 
climates  and  seasons. 

The  mortality  is  nearly  equal  in  the  two  sexes,  but  age  has  a  marked 
influence  on  the  percentage  of  deaths.  Comparatively  few  contract 
scarlet  fever  under  the  age  of  one  year,  and  the  period  of  its  greatest 
mortality,  and  also  of  its  greatest  frequency,  is  between  the  ages  of  one 
and  six  years.  The  following  are  statistics  beai'ing  on  the  relation  of 
the  age  to  the  percentage  of  deaths : 


From  the  close 

From  the  5th  to 

Under  1  year. 

of  1st  till  close 
of  5tli  year. 

the   12th 
year. 

Fleishman, 

Cases 

8 

204 

260 

Deaths 

6 

88 

51 

Ist  to  close  of 

Gth  to  12th 

From  the  12th 

6th  year. 

year. 

to  20th  year. 

Kraus, 

Cases 

.       13 

113 

106 

40 

Deaths 

4 

29 

10 

7th  to  ICth  yeer. 

2 

Voit, 

Cases 

5 

166 

109 

Deaths 

1 

24 

10 

Koset, 


PROGNOSIS. 

Under  1  year. 

From  1st  to  close 
of  5th  year. 

Cases 

.       43 

lo6 

Deaths 

.       16 

31 

Under  5  years 

5tli  to  10th  year. 

Cases 

.      101 

120 

Deaths 

.       21 

20 

243 

Over  5  years. 


10th  to  l.ith  year.   Over  15  years. 
Russiger,      Cases        .     101  120  47  27 

Deaths     .21  20  3  0 

These  statistics,  which  I  believe  correspond  with  the  observations  of 
others,  show  that  although  few  cases  occur  in  the  first  year,  the  per- 
centage of  deaths  is  large,  and  that  a  majority  of  the  total  deaths  from 
this  malady  occur  under  the  age  of  six  years.  After  the  sixth  year  the 
greater  the  age  the  less  the  proportionate  number  of  deaths. 

Scarlet  fever  is  liable  to  so  many  complications  and  sequel*  that  a 
physician  should  not  predict  a  certain  favorable  termination  in  the 
beginning,  however  mild  and  regular  the  symptoms  may  be.  But  a 
favorable  result  may  be  expected  if  the  attack  be  mild,  the  efflorescence 
appear  at  the  proper  time  and  extend  over  the  entire  surface,  the  angina 
be  moderate  and  accompanied  by  little  or  no  (Cellulitis  or  adeniiis,  with 
pulse  under  140,  temperature  not  above  103°,  and  no  marked  nervous 
symptoms. 

Whether  the  complications  or  sequelae  be  dangerous  depends  upon 
their  character.  Rheumatism  has  never  in  my  practice  been  dangerous, 
nor  has  it  materially  retarded  convalescence,  except  when  it  affected  the 
heart,  causing  pericarditis  or  endocarditis,  when  it  involves  great  danger. 
Nephritis,  if  it  be  moderate,  attended  by  little  albuminuria  and  serous 
eff"usion,  and  by  the  occurrence  of  few  renal  casts  in  the  urine,  commonly 
ends  favorably  under  judicious  treatment,  as  we  have  already  stated; 
but  severe  nephritis,  with  abundant  albuminuria  and  casts  and  serous 
effusions,  soon  gives  rise  to  alarming  symptoms,  and  is  the  cause  of  death 
in  a  considerable  number  of  in.stances.  A  similar  remark  is  applicable 
to  the  angina,  which  occurs  in  all  grades  of  severitv.  If  it  be  attended 
by  much  cellulitis,  Avith  con.siderable  ulceration  or  necrosis,  the  state  is 
one  of  danger,  in  consequence  of  tlie  difficulty  in  administering  sufficient 
nutriment,  as  well  as  from  the  diminished  assimilation  and  tlie  loss  of 
strength  due  to  the  prolonged  inflammatory  fever,  the  se})tic  poisoning, 
and  the  occasional  hemorrliages.  Complication  by  pharyngeal  or  nasal 
diphtheria,  now  so  common  where  diphtheria  is  endemic,  also  greatly 
increases  the  danger. 

^lany  cases,  even  when  their  course  is  normal  and  without  comjdica- 
tions,  involve  danger,  and  some  are  necessarily  fatal,  from  the  direct 
effect  of  scarlatinous  blood-poisoning.  Such  are  grave  or  malignant 
forms  of  the  disease  Avhich  the  exj)cricnccd  eye  recognizes  at  a  glance. 
Death  often  occurs  rapidly  from  the  tox:emia.  Such  cases  are  charac- 
terized by  high  temf)crature  (105°  or  100°),  rapid  pul.se,  dusky-red  hue 
of  the  surface  from  languid  capillary  circulation,  pungent  heat,  frcMjuent 
vomiting,  diarrhocal  stools,  a  dry-brown  tongue,  and  marked  nervous 
symptoms,  such  as  delirium,  great  restlessness,  or  stupor.  Not  a  few 
in  this  form  of  scarlet  fever  take  eclampsia,  which  is  apt  to  be  severe 
and  repeated,  and  to  end  in  fatal  coma. 

Other  inflammatory  complications    and  sec^uelsB,   which   have  been 


244:  SCARLET    FEVER. 

described  in  the  preceding  pages,  retard  convalescence  and  jeopardize 
the  life  of  the  patient,  such  as  empyema,  endocarditis,  pericarditis,  and 
pneumonia.  Otitis  media  is  seldom  immediately  dangerous,  although  it 
may  be  painful  and  involve  serious  consequences,  even  a  fatal  meningitis, 
as  has  been  stated  above,  after  months  or  years  of  otorrhoea.  Anoma- 
lous cases  are  believed  to  be,  as  a  rule,  more  dangerous  than  such  as  are 
attended  by  an  early  and  full  efflorescence  and  have  the  usual  symptoms. 

TreaTiMENT.  Prophylaxis. — Since  the  discovery  by  Jenner  of  the 
prophylactic  power  of  vaccination  as  regards  smallpox,  the  attention  of 
the  profession  has  been  freipiently  directed  to  the  prevention  of  scarlet 
fever.  Belladonna  has  been  employed  for  this  purpose  by  a  class  of 
practitioners  who  believe  in  the  theory  that  an  agent  which  produces 
symptoms  similar  to  those  of  a  disease  is  antagonistic  to  that  disease, 
and  therefore  tends  to  prevent  it,  or,  if  it  be  present,  to  render  it 
milder;  and  since  this  herb  causes  an  efflorescence  upon  the  skin  and 
redness  of  the  fauces,  it  was  selected  as  the  proper  preventive  and 
remedial  agent  for  scarlet  fever.  Its  use,  however,  for  this  purpose  has 
been  fruitless,  and  it  is  now  nearly  or  quite  discarded. 

It  is  probable,  from  a  considerable  number  of  observations,  that 
scarlet  fever  occasionally  occurs  in  the  domestic  animals  during  epidemics 
of  the  disease  in  children.  It  is  stated  that  Spinola  observed  it  in  the 
horse;  that  Heiui  saw  a  dog  that  occupied  the  same  bed  Avith  a  scarla- 
tinous patient  sicken  Avith  fever,  which  was  folloAved  by  desquamation; 
that  Letheby  saw  scarlatina  in  swine,  and  Kraus  in  young  cattle. 
Prominent  veterinary  surgeons,  as  Williams,  of  Great  Britain,  admit  the 
occurrence  of  scarlatina  in  animals,  and  the  hope  has  arisen  that  since 
smallpox  is  modified  in  cattle  so  as  to  afford  us  the  vaccine  virus,  per- 
haps scarlet  fever  may  also  be  modified  by  passing  through  one  of  the 
lower  animals,  so  that  a  milder  and  less  fatal  form  of  the  disease  might 
be  produced  in  man  by  inoculation  from  the  animal.  This  theory, 
though  it  deserves  investigation,  is  far  from  being  established.  It  has 
not  yet,  so  far  as  I  am  aware,  been  shown  that  scarlet  fever  is  milder  in 
any  animal  than  in  man,  nor,  if  we  admit  that  it  is  modified  in  the 
animal,  is  it  certain  that  the  disease  could  be  returned  to  man  in  the 
modified  form.  In  the  N.  Y.  3Iedical  Record  for  INIarch  24,  1883, 
5ome  experiments  are  detailed  by  S.  W.  Strickler  of  Orange,  New 
Jersey.  He  cites  the  experiments  of  Gaze  and  Feltz,  who  injected 
scarlatinal  blood  under  the  skin  of  sixty-six  rabbits,  and  of  these  sixty- 
tAvo  died  within  eighteen  hours  to  fourteen  days,  which  indicated  a 
highly  poisonous  state  of  the  blood  employed,  either  septic  or  scarla- 
tinous, and  certainly  no  mitigation  of  the  virulence  of  the  scarlet  fever. 
Strickler  obtained  from  AVilliams,  of  Edinburgh,  nasal  mucus  from  a 
horse  supposed  to  have  scarlatina,  and  Avith  it  inoculated  tAvelve  children, 
all  of  whom  had  sores  at  the  point  of  inoculation,  with  redness  of  the 
skin  around  the  sores,  and  in  some  instances  sAvelling  of  the  adjacent 
lymphatic  glands.  It  is  stated  that  the  children  thus  inoculated  did 
not  contract  scarlet  fever  subsequently  Avhen  they  Avere  exposed  to 
it.  Obviously,  there  is  a  serious  objection  to  such  experiments  upon 
children,  so  that  they  may  not  be  repcate<l,  but  a  movement  has  been 
made  in  one  of  the  Ncav  York  medical  societies  looking  to  the  appoint- 


TREATMENT  —  PROPHYLAXIS.  245 

merit  of  a  competent  committee  to  investigate  them.  Some  of  the  promi- 
nent veterinary  surgeons  of  this  city  do  not  attach  much  importance  to 
the  experiments  thus  far  made,  since  they  are  in  doubt  whether  the  virus 
empkjyed  was  that  of  the  genuine  disease. 

It  is  a  matter  of  great  interest  and  importance,  and  one  not  yet  eluci- 
dated, whether  or  to  what  extent  disinfectant  and  antiseptic  remedies 
administered  internally,  prevent  the  occurrence  of  the  infectious  maladies 
in  those  who  have  been  exposed,  and  aid  in  curing  those  who  are  sick 
with  them.  Sodium  sulpho-carbolate,  from  which,  by  decomposition  in 
the  system,  carbolic  acid  is  supposed  to  be  set  free,  has  been  used  for 
this  purpose.  It  is  administered  to  adults  in  doses  of  ten  to  thirty 
grains,  and  to  children  in  doses  proportionate  to  their  age.  Declat  has 
prepared  a  syrup  of  phenie  (carbolic)  acid  as  a  preventive  and  curative 
agent  in  the  infectious  diseases.  It  is  now  employed  by  several  of  the 
New  York  physicians,  but  thus  far  the  statistics  of  its  use  are  not  suffi- 
cient to  determine  its  efficacy.  It  is  a  question  whether  the  so-called 
antiseptics  can.  on  account  of  their  toxic  properties,  be  used  with  safety 
in  doses  sufficiently  large  to  be  antidotal  to  the  specific  principle  of  any 
of  the  infectious  maladies. 

It  is  not  my  intention  to  recommend  in  this  treatise  any  remedial 
agent  that  has  not  been  fully  tried  and  its  efficaqy  determined ;  but 
from  observations  made  by  myself  in  nearly  twenty  families  in  which 
scarlet  fever  was  prevailing,  I  am  convinced  that  boracic  acid  (acidum 
boricum),  an  antiseptic  recently  introduced  into  our  Pharmacopoeia, 
deserves  trial  as  a  prcv'entive  and  antidote  of  scarlet  fever  as  well  as 
diphtheria.  The  good  result  in  my  practice  from  the  use  of  this  agent, 
which  oidy  extends  over  about  six  months,  may  be  due  to  the  present 
type  of  scarlet  fever,  but  I  have  been  surprised  at  the  favorable  progress 
of  the  cases  which  appeared  very  grave  in  the  beginning,  at  the  small 
mortality,  and  at  the  large  proportion  of  well  ciiildren  exposed  to  scar- 
latinous cases  that  escaped  infection,  to  whom  this  medicine  was  regu- 
larly administered.  Boric  (boracic)  acid  has  been  recently  used  by 
aurists  with  remarkable  success  in  suppurating  and  granulating  otitis 
media,  and  by  oculists  as  an  eye-wash,  Yj.  R.  Squibb  says  of  it 
{Epliemi'i'iH,  May,  1883):  "A  solution  saturated  at  ordinary  tempera- 
tures contains  between  4  and  5  per  cent It  is  a  very  bland  and 

soothing  application,  whether  applied  in  powder  or  solution,  relieving 

irritation  and  reducing  suppuration It  has  been  administered 

internally  in  large  doses  without  any  disturbing  effect.  The  prepara- 
tion which  I  have  employed  is  one  found  in  the  shops,  with  the  name 
listerine,  prepared  by  a  Western  phannaceutical  firm.  It  contains, 
accorTTing  to  the  manufacturers,  tin;  ''essential  antiseptic  constituents 
of  thyme,  eucalyptus,  baptisia,  gaultheria,  and  mentlia  arvensis,"  and 
also  two  grains  of  benzo-boracic  acid  in  each  drachm.  The  dose  of 
listerine  which  I  have  employed  for  an  adult  is  one  teaspoonful,  con- 
sideralTly  (ji luted  with  cold  water.  A  child  of  five  years  can  take  ten 
to  fifteen  di()|)S  every  two  to  four  hours.  I  call  the  attention  of  the 
j)rof(.'ssiou  to  the  use  of  boracic  acid  as  an  antidote  to  the  scarlatinous 
poison,  without  sufficient  experience  to  enable  me  to  speak  i)ositively 
of  its  efficacy,  but  with  the  hope  and  expectation,  from  observing  its 


246  SCARLET    FEVER. 

apparent  effects  in  seventeen  families  afflicted  with  scarlet  fever,  that  it 
will  be  found  a  useful  addition  to  our  means  of  controlling  this  much- 
dreaded  and  fatal  malady. 

In  the  present  state  of  our  knowledge  the  most  reliable  and  certain 
prophylaxis  is  the  isolation  of  patient  and  nurses,  and  the  thorough  and 
judicious  employment  of  disinfectants  upon  their  persons  and  in  the 
apartments.  All  furniture  and  articles  not  absolutely  required  should 
be  removed  from  the  sick-room,  and  no  one  should  be  allowed  to  enter 
it  except  the  medical  attendant  and  nurses.  Constant  ventilation  should 
be  insisted  on  by  lowering  the  uj^er  and  raising  the  lower  sash  of  the. 
window  two  or  three  inches  in  mild  weather.  Even  in  stormy  Aveather 
sufficient  ventilation  can  be  obtained  in  this  way  without  exposing  the 
patient  to  currents  of  ajr,  which  should  be  avoided. 

Since  the  exhalations  from  the  body,  the  various  excretions,  and  the 
epidermic  cells  shed  so  abundantly  in  the  desquamative  period  contain 
the  scarlatinous  poison,  measures  should  be  employed  to  disinfect  them, 
in  so  far  as  the  comfort  and  well-being  of  the  patient  will  allow.  A^essels 
which  receive  the  excretions  should  contain  carbolic  acid,  chloride  of 
lime,  or  other  disinfectant,  and  they  should  be  immediately  emptied  and 
cleaned  after  use.  By  the  frequent  application  of  disinfecting  w;ii£hes 
to  the  nost^rils  and  fauces  the  secretions  from  these  surfaces  are  to  a 
great  extent  deprived  of  their  contagiousness.  If  otorrhoe_a.  occur, 
boracic  acid,  so  serviceable  in  its  treatment,  acts  as  a  disinfectant,  but 
in  addiiion  the  ear  should  be  syringed  with  warni  carbohzed  water,  one 
drachm  of  carbolic  acid  to  the  pint  of  water,  and  this  should  be  con- 
timied  during  convalescence,  for  cases  occur  which  show  that  the  dis- 
charge from  the  ear  is  probably  the  vehicle  by  which  the  virus  is 
communicated.  Even  as  late  as  the  fourth  week  after  the  disapjjear- 
ance  of  the  rash  children  in  scarlet  fever  ejTperience  relief  from  inunc- 
tion of  the  surface,  and  if  carbolic  acid  be  added  to  the  substance  which 
is  employed  for  this  purpose,  and  the  inunction  be  made  twice  daily  over 
the  entire  surfice,  contamination  of  the  air  through  the  exfoliations  and 
exhalations  from  the  skin  is  in  great  part  prevented.  The  late  William 
Budd,  of  Bristol,  England,  was  in  the  habit  of  recommending  inunction 
of  the  surface  twice  daily  with  sweet  oil,  which  answered  the  purpose 
of  preventing  dissemination  of  epidermic  particles  through  the  air  :  and 
we  will  presently  see  how  successful  were  his  precautionary  measures. 

A  convalescent  child  should  not  be  allowed  to  mingle  with  other  chil- 
dren till  t)iree  or  four_\vecks  have  elapsed  and  desquamation  has  ceased; 
and  all  Avho  are  Hable  to  tal<e  the  malady  should  be  excluded  from  the 
room  in  which  a  case  has  occurred  for  a  longer  period,  and  until  it  has 
been  thoroughly  disinfected  Ijy  burning  sulphur  or  other  methods. 

The  New  York  Board  of  Health  enforces  the  following  excellent  regu- 
lations to  prevent  the  spread  of  scarlet  fever  as  well  as  other  acute  in- 
fectious maladies : 

''  Care  of  Patients. — The  patient  should  be  placed  in  a  separate  room, 
and  no  person  except  the  physician,  nurse,  or  mother  alloAved  to  enter 
the  room  or  to  touch  the  bedding  or  clothing  used  in  the  sick-room  until 
they  have  been  thoroughly  disinfected. 


HYGIENIC    TBEATMEXT.  247 

"  Infected  Articles. — All  clothing,  bedding,  or  other  articles  not  abso- 
lutely necessary  for  the  use  of  the  patient  should  be  removed  from  the 
sick-room.  Articles  used  about  the  patients,  such  as  sheets,  pillow- 
cases, blankets,  or  clothes,  must  not  be  removed  from  the  sick-room 
until  theymive  been  disinfected  by  placing  them  in  a  tub  with  the  fol- 
lowing disinfecting  fluid ;  ejo^ht  ounces  of  sulphate  of  zinc,  one  ounce 
of  carbolic  acid,  three^allons  of  ■s\;ater.  Tliey  sliould  be  soakecTm^is 
fluid  for  at  least  an  hour,  and  then  placed  in  boiling  water  for  washing. 

"  A  piece  of  musTm  one  foot  square  should  be  dipped  in  the  same 
solution  and  suspended  in  the  sick-room  constantly,  and  the  same 
should  be  done  in  the  hallway  adjoining  the  sick-room. 

"All  vessels  used  for  receiving  the  discharges  of  patients  should  have 
some  of  the  same  disinfecting  fluid  constantly  therein,  and  immediately 
after  being  used  by  the  patient,  should  be  emptied  and  cleansed  with 
boiling  water.  Water-closets  and  privies  should  also  be  disinfected 
daily  with  the  same  fluid  or  a  solution  of  chloride  of  iron,  one  pound 
to  a  gallon  of  water,  adding  one  or  two  ounces  of  carbolic  acid. 

'"AH  straw  beds  should  be  burned. 

"  It  is  advised  not  to  use  handkerchiefs  about  the  patient,  but  rather 
soft  rags,  for  cleansing  the  nostrils  and  mouth,  which  should  be  imme- 
diately thereafter  burned. 

"The  ceilings  and  side-walls  of  a  sick-room  after  removal  of  the 
patient  should  be  thoroughly  cleaned  and  lime-washed,  and  the  Avood- 
work  and  floor  thoroughly  scrubbed  with  soap  and  water." 

By  such  measures  of  prevention  there  can  be  no  doubt  that  the 
number  of  cases  of  scarlet  fever  would  be  greatly  reduced. 

Budil  for  years  recommended  similar  precautions  in  the  families  which 
he  attended,  and  the  fjllowing  is  his  testimony  in  regard  to  the  result: 
"The  success  of  this  method  in  my  own  hands  has  been  very  remark- 
able. For  a  period  of  nearly  twenty  years,  during  Avhich  I  have  em- 
ployed it  in  a  very  wide  held,  I  have  never  known  the  disease  to  spread 
beyond  the  sick-room  in  a  single  instance,  and  in  very  few  instances 
within  it.  Time  after  time  I  have  treated  this  fever  in  houses  crowded 
from  attic  to  basement  with  children  and  others,  who  have  nevertheless 
escaped  infection.  The  tAvo  elements  in  the  method  are  separation  on 
tlie  one  hand,  and  disinfection  on  the  other."  ^ 

IIy(jII?;nic'  Tiii:at.mi;nt. — The  room  o!-eupied  by  a  scarlatinous  patient 
should  be  commodious  and  sufficiently  ventilated.  Its  temperature 
should  be  uniform  at  about  J^_  diirinrr  the  course  of  the  fever.  When 
the  tiivxT  begins  to  abate  and  desnuamation  commences,  a  temperature 
of  72°  to  7;")°  is  preferable,  .^o  tliat  there  is  less  danger  that  the  surface 
may  be  chilled  during  unguaided  moments,  as  at  night,  when  the  body 
may  be  accidentally  uncovered,  since  sudden  cooling  of  the  surface  at 
this  time  may  cause  nephritis  or  some  other  dangerous  inflamnuition. 
Henoch  does  not  believe  in  the  theory  that  the  nephritis  is  commonly 
jtroduced  by  catching  cold,  but  many  observations  show  that  those  who 
are  carefully  protected  from  vicissitudes  of  temperature,  who  remain 
during  convalescence  in  a  warm   room,  and  are  protected  by  abundant 

»  British  Medical  .Journal,  .J.inuury  9,  18G9. 


2-18  SCARLET    FEVER. 

clothing,  more  frequently  escape  this  complication  than  such  as  are 
under  no  restraint  of  this  kind  and  are  carelessly  exposed  in  times  of 
changeable  weather.  Nevertheless,  it  is  true  that  a  certain  proportion 
suffer  from  nephritis  however  judicious  the  after-treatment  may  be. 
The  best  hygienic  management  does  not  always  prevent  its  occurrence. 
The  patient  should  not,  therefore,  leave  the  house  until  four  weeks  after 
the  becjinning  of  the  fever,  and  in  inclement  Aveather  not  till  a  longer 
time  has  elapsed.  So  long  as  desquamation  is  going  on  and  the  skin 
has  not  regained  its  normal  function,  the  patient  should  remain  indoor, 
and  when  finally  he  is  allowed  to  leave  the  house  he  should  be  warmly 
clothed. 

Therapeutic  Treatment. — In  order  to  treat  scarlet  fever  success- 
fully, it  is  necessary  to  bear  in  mind  that  it  is  a  self-limited  disease, 
running  for  a  certain  time  and  through  certain  stages,  and  that  it  is  not 
abbreviated  by  any  known  treatment.  Therapeutic  measures  can  only 
moderate  its  symptoms  and  render  it  milder.  The  severity  of  the  dis- 
ease is  indicated  by  its  symptoms,  and  the  symptoms  are  to  a  certain 
extent  under  our  control. 

Mild  Cases. — A  patient  with  a  temperature  under  103°,  and  with 
only  a  moderate  angina,  does  not  reciuire  active  treatment,  but,  however 
light  the  disease,  he  should  always  be  in  bed  and  in  a  room  of  uniform 
temperature,  as  stated  above.  Instances  have  come  to  my  notice  in  the 
poor  f  imilies  of  New  York  in  which  scarlet  fever  was  not  diagnosticated, 
and  the  patients  Avere  allowed  to  go  about  the  house,  and  even  in  the 
open  air,  in  the  eruptive  stage,  till  some  severe  complication  or  an 
aggravation  of  the  type  created  alarm  and  medical  advice  was  sought, 
when  it  appeared  that  a  grave  and  dangerous  condition  had,  through 
carelessness  and  ignorance,  resulted  from  a  mild  and  favorable  form  of 
the  malady.  The  physician,  when  summoned  to  a  case  however  mild, 
should  never  fail  to  take  the  temperature,  note  the  pulse,  inspect  the 
fauces,  and  inquire  in  reference  to  the  fecal  and  urinary  evacuations, 
that  he  may  detect  early  any  unfavorable  changes  Avhich  may  occur. 

Since  in  all  cases  angina  and  more  or  less  blood-deterioration  are 
present,  the  following  prescription  will  be  found  useful  in  mild  as  well 
as  severe  scarlet  fever : 

U. — Potiips.  rhl  >rat ^\]. 

Tr.  feiri  chluridi  .         .         .         .         .         .     fzij. 

Syrupi ^5'^. — Misce. 

SifC- — Half  a  tea«poonfnl  every  hour  to  two  hours  to  a  child  of  three  years;  a 
teaspoon ful  to  a  child  of  six  years. 

Small  doses  of  this  medicine  frequently  administered  act  beneficially 
on  the  surface  of  the  throat  and  tend  to  prevent  the  anaemia  which  is 
so  common  after  scai-let  fever.  If  the  medicine  be  given  gradually 
diluted  with  only  a  moderate  amount  of  water,  the  effect  is  better  on 
the  inflamed  fauces.  Potassium  chlorate  is  known  to  be  an  irritant  to 
the  kidneys  in  large  doses,  causing  intense  hyperyemia  of  these  organs, 
with  bloody  urine  or  suppression  of  urine.  The  melancholy  fate  of 
Fountaine,  who  died  from  the  effects  of  one  ounce  of  this  medicine,  is 
known  to  the  profession.      I  have  seen  a  similar  instance  in  a  child. 


ORDINARY    CASES    AND    CASES    OF    SEVERE    TYPE.     249 

But  doses  of  one  to  four  grains,  according  to  the  age,  can  be  admin- 
istered with  safety  to  children,  so  that  half  a  drachm  to  a  drachm  and 
a  luilf  are  taken  in  twenty-four  hours.  A  quantity  much  exceeding 
this  amount  involves  risk.  In  mild  cases  it  is  not  necessary  to  treat  tlie 
throat  by  topical  measures,  <he  above  prescription  producing  sufficient 
local  effect,  but  canmho rated  oil  may  be  used  externally.  I  ordinarily 
prescribe  quinine  in  small  doses  for  this  form  of  scarlatina,  as  in  the 
following  formula : 

B;. — Qiinifc  sulphnt gr.  xvj. 

Ext.  glycyrrhi/.ffl  .         .         .         .         .         .      5^*- 

Syr.  pruiii  virginianae  .....     f^ij. — Misce. 

Sior  — One  teacpoonful  every  fourth  hour  to  a  child  of  three  to  five  years,  the 
polasiiiim  chlorate  and  iron  luixture  being  administered  twice  between. 

The  treatment  of  scarlatina  by  antiseptic  remedies  will  be  considered 
hereafter. 

The  itching  and  dryness  of  the  surface,  which  increase  the  discomfort 
of  the  patient  in  miliTas  well  as  severe  scarlatina,  are  relieved  by  fre- 
quently anointing  the  whole  body  with  vaseline,  cold  cream,  or  butter 
of  cocoa.  Carbolic  acid  is  an  efficient  remedy  for  pruritus,  AvhileTTis 
alscTaTciisinfecfaril.     It  may  be  used  in  the  following  formula : 

li  — Afidi  CHrbolici.    .......      ^]. 

Vaseline      ........      51V. — Misce. 

Sig  — To  be  applied  over  the  entire  surface. 

In  New  York  leaf  lard  has  long  been  employed  as  an  unguent  over 
the  entire  surface  in  scarlet  fever,  and  patients  experience  benefit  from 
it.  Alcohol  and  water  or  vinegar  and  water  are  sometimes  employed 
for  the  same  purpose.  The  linen  should  be  changed  every  day  and  the 
bed  thoroughly  aired. 

Okdinauy  C.vses  and  Cases  of  Severe  Type. — A  safe  tempera- 
ture in  scarlet  fever  may  be  considered  at  or  below  108°.  If  it  rise 
above  this,  measures  designed  to  abstract  heat  are  very  important — more 
important  even  in  many  cases  than  the  medicinal  agents  which  are  com- 
monly used  to  combat  this  disease.  Since  a  high  tem])crature  retards 
assimilation;  promotes  deleterious  tissue  change,  and  causes  rapid  emacia- 
tion and  loss  of  strength,  measures  designed  to  reduce  it  are  urgently 
neede<l.  "The  production  of  heat  depends  chiefly  on  oxidation  of  the 
constitutent.s  of  the  body"  (Billroth).  Therefore  fever  indicates  an 
increase  of  the  oxidation  and  a  molecular  disintegration  above  the 
healthy  standard.  Hence,  the  augiiientation  of  urea  in  the  urine  and 
the  progressive  emaciation  ancl  loss  of  weight  which  chanicteri/e  the 
fcttrile  state.  Fever  also  diminishes  the  secretions  by  which  food  is 
digested  and  destroys  the  appetite,  .so  that  rejiair  of  the  \\aste  is  in- 
sufficient. Moreover,  a  high  temperature  continuing  for  a  time  tends 
til  i)r<)duce  degenerative  changes,  albuminous  and  fatty,  in  the  tissues, 
the  more  rapidly  the  higher  the  tenqx-rature,  so  that  the  functions  of 
organs  are  seriously  im])aired.  Among  the  most  dangerous  of  the 
tissue-changes  is  granulo-fatty  degeneration  of  the  muscular  filjres  of 
the  heart.     In  dogs  and  rabbits  that  have  perished  from  a  high  tenq)era- 


250  SCARLET    FEVER. 

ture  artificially  produced  by  experimenters  granular  clouding  of  the 
elementary  tissues  has  been  found  after  death.'  A  high  temperature, 
therefore,  in  itself  involves  danger,  and  if  it  occur  in  an  ataxic  disease 
like  scarlet  fever,  and  be  protracted,  it  greatly  diminishes  the  chances 
of  a  favorable  issue. 

The  temperature  can  be  reduced  without  shock  or  injury  to  the  child 
by  the  judicious  use  of  cold  water  externally.  The  cold  water  treat- 
ment is  not  necessary  if  the  temperature  be  under  103°,  though  useful 
if  judiciously  employed  by  sponging  when  the  temperature  is  at  102° 
or  103°  ;  but  if  it  rise  above  103°  it  is  required,  and  the  more  urgently 
the  higher  the  temperature.  The  external  use  of  cold  water  as  an 
antipyretic  in  the  febrile  diseases  is  now  most  universally  recommended 
bv  physicians,  but  it  still  meets  with  opposition  on  the  part  of  families, 
especially  in  the  treatment  of  the  exanthematic  fevers,  and  the  direc- 
tions for  its  employment  are  therefore  not  apt  to  be  fully  carried  out 
during  the  absence  of  the  medical  attendant.  The  old  theory  that  the 
fevers  require  warmth  and  sweating  has  such  a  firm  hold  on  the  popular 
mind  that  some  years  longer  will  be  required  for  its  removal. 

The  modes  of  applying  cold  water  recommended  by  cautious  and 
experienced  physicians  are  various.  Von  Ziemssen  recommended  that 
the  patient  be  immersed  in  water  at  a  temperature  of  90°,  and, cool 
water  be  gradually  added  till  the  temperature  fall  to  77°.  In  a  few 
minutes  the  patient  is  returned  to  his  bed,  his  surface  dried,  and  he  is 
covered  by  the  proper  bedclothes,  Avhen  his  temperature  will  probably 
be  found  reduced  two  or  two  and  a  half  degrees.  If  the  patient  com- 
plain of  chilliness  or  his  pulse  be  feeble,  he  should  be  immediately 
removed  from  the  bath  and  stimulants  administered,  either  whiskey  or 
brandy,  for  if  the  extremities  remain  cool  and  the  capillary  circulation 
sluggish,  the  effect  may  be  injurious,  since  some  internal  inflammation 
may  arise  to  complicate  the  fever.  Under  such  circumstances  increased 
alcoholic  stimulation  is  required. 

The  cfthl  Jiack  is  also  effectual  for  reducing  the  temperature.  The 
patient  Is  placed  upon  a  mattrass  protected  by  oil  cloth,  and  is  covered 
by  a  sheet  Avrung  out  of  water  at  a  temperature  ofJ70°.  This  is  covereil 
by  one  or  two  blankets.  In  half  an  hour  he  is  returned  to  bed,  and  will 
be  found  to  have  a  temperature  two  or  three  degrees  less  than  that  before 
the  bath.  Another  method  is  to  apply  the  sheet  wxung  out  of  water  at 
_^°,  and  then  reduce  the  temperature  by  adding  Avatcr  at  a  lower  degree 
from  a  sprinkler.  In  most  cases,  however,  I  ])refer  to  reduce  the  tem- 
perature by  the  constant  application  to  the  head  of  an  India-rubber  bag 
contairimg  ice.  The  bags  should  be  about  one-third  fillet'l,  so  that  it 
should  fit  over  the  head  like  a  cap.  At  the  same  time,  as  a  potent  means 
of  abstracting  heat,  at  least  when  the  temperature  is  at  or  above  104°,  a 
similar  application  should  be  made  by  an  elongated  rubbeijba^  lying  over 
the  neck  and  extending  from  ear  to  ear.  Cold  applied  over  the  great 
vesseTs~"of  the  neck  promptly  abstracts  heat  from  the  blood,  while  it 
diminishes  the  pharyngitis,  adenitis,  and  cellulitis;  which  is  an  impor- 

1  See  experiments  by  Mr.  J.  W.  Legg,  Lond.  Path.  Soc.  Trans.,  vol.  xxiv., 
and  otlierj. 


ORDIXAPwY    CASES    AXD    CASES    OF    SEVERE    TYPE.       251 

tant  gain.  At  the  same  time,  it  is  proper  to  sponge  freciuentW  the  hands 
and  arms  with  cool  -water.  If  the  temperature  "vvith  this  treatment  be 
not  sufficiently  reduced,  one  or  two  thicknesses  of  muslin  ireijuently 
Avruji^out  of  ice-water  should  be  placed  along  the  arms  and  upon  either 
side  of  the  face.  By  such  local  measures,  which  are  agreeable  to  the 
patient  and  without  any  shock,  or  perturbing  effect  on  the  system,  we 
can  reduce  the  temperature  two  or  three  degrees.  By  adding  alcohol  or 
one  of  the  alcoholic  compounds  to  the  water  the  popular  objection  to  the 
use  of  coM  is  overcome. 

Trousseau,  in  the  treatment  of  sthenic  cases  attended  by  a  high  tem- 
perature, was  in  the  habit  of  placing  the  patient  naked  in  a  bath-tub,  and 
directing  three  or  four  pailfuls  of  water  to  be  thrown  over  him  in  a 
space  of  time  varying  froin  one  quarter  of  a  minute  to  one  minute,  after 
which  he  was  returned  to  bed  and  covered  by  the  bedclothes  without 
bein2  dried.  Reaction  immediatelv  occurred,  often  with  more  or  less 
perspiration.  This  treatment  Avas  repeated  once  or  twice  daily,  according 
to  the  gravity  of  the  symptoms.  Trousseau,  p.lluding  to  this  treatment, 
says:  "I  have  never  administered  it  without  deriving  some  benefit." 
But  the  a|)plication  of  cold  water  in  a  manner  that  does  not  excite  or 
frighten  the  patient  seems  preferable.  Henoch,  having  a  large  experi- 
ence, gives  the  following  advice  in  reference  to  the  water  treatment: 
"  If  the  fever  continue  high  and  the  apparently  malignant  symptoms 
described  above  develop,  the  head  should  be  covered  with  an  ice-bag, 
....  and  the  child  placed  in  a  lukewarm  bath,  not  un<ler  2-3°  R. 
(88.2o°F.).  I  decidedly  oppose  cooler  baths,  because  in  scarlatina,  which 
presents  a  tendency  to  heart-failure,  cold  may  produce  an  unexpected 
rapid  collapse  more  tlian  in  any  other  afection.  But  I  strongly  recom- 
mend washing  tlie  entire  body  every  tlu'ce  hours  Avith  a  sponge  dipped 
in  cool  water  and  vincjiar/'^  In  grave  cases  with  a  high  temperature  the 
application  of  cold  should  be  sufficient  to  produce  a  decided  reduction  of 
heat,  otherwise  the  full  benefit  from  its  use  is  not  detained.  With  proper 
stimulation  aiul  proper  ])i'ecautions  jirostration  docs  not  occur  frctin  the  I 
ice-bags  to  tiie  head  and  neck  and  codI  sponging  of  other  parts,  so  long 
as  the  temi)erature  does  not  fall  brlow  102°  or  103°.  The  danger  I 
alluded  to  by  Henoch  can  only  occur  from  the  use  of  the  pack  or  general 
bath,  and  the  water  treatment  can  be  efficiently  carried  out  and  the  tem- 
perature sufficiently  reduced  without  resorting  to  these.  Even  Currie, 
of  Edinburgh,  who  first  drew  attention  to  the  Ijcnefitfrom  the  cold  water 
treatment  of  scarlet  fever  in  an  age  when  the  sweating  treatment,  and 
even  the  exclusion  of  cool  ami  fresh  air  from  the  apartment,  Avere  deemed 
necessary,  recommended  cold  effusion  only  in  sthenic  cases  Avith  full  an<I 
strong  pulse,  and  he  mentions  as  a  Avarnjxig  two  cases  Avith  ([uick  and 
feebje  pulse  and  cool  extremities  in  Which  death  occurred  immediately 
after  tlie  use  of  tIie~Av:iter. 

So<lium  salicylate  is  in  some  instances  a  useful  remedy  i"  >r  tlie  rediice- 
tion7)f  heat  in  the  infectious  diseases.  It  seems  to  be  more  decidedly 
antipyretic  than  quinine  in  the  febrile  and  infiammatory  diseases,  though 
somewhat  depressing  to  the  heart's  action.     James  Oouldrey  writes  to 

*  Diseases  of  Children. 


252  SCARLET    FEVER, 

the  London  Lancet  (Dec.  1882,  p.  10G4)  that  lie  lias  derived  great 
benefit  from  its  use  in  seven  cases  of  scarlet  fever.  lie  administered  it 
every  |wo_hiiurs  till  ringing  in  the  ears  was  produced,  and  afterward 
every  four  hours,  prescribing  one  grain  for  each  year  in  the  age  of  the 
patient.  It  is,  in  my  opinion,  a  proper  remedy  when  the  pulse  is  full 
and  strong  and  the  temperature  is  not  suilicieiitly  reduced  by  the  cold 
water  treatment. 

Aconite  and  veratrum  viride  reduce  fever,  but  they  are  too  depressing 
to  be  safely  employed  in  grave  scarlet  fever,  and  their  antipyretic  effect 
is  less  than  that  of  water.  The  use  of  di^gitalis  might  be  suggested  by 
the  quick  and  feeble  pulse  in  certain  cases~tTiat  are  attended  by  high 
teniperature,  but  thej  udginent  of  the  profession  is  for  the  most  part  against 
its  use  in  such  cases.  What  Stille  and  Maisch  state  of  its  em])loyment 
in  typhoid  fever  appears  equally  applicable  to  scarlet  fever:  "Even  its 
advocates  have  not  shown  that  it  abridges  the  disease  or  lessens  its 
mortality,  while  it  is  abundantly  demonstrated  to  impair  the  digestion, 
reduce  the  strength,  and  even  to  occasion  sudden  death.  The  use  of 
digitalis  in  other  forms  of  fever  is  equally  unsatisfactory,  and  justifies 
the  judgment  of  Traube,  that  the  true  field  of  action  for  digitalis  is  not 
fever." 

Qnuinine  is  the  medicine  Avliich  above  all  others  has  been  heretofore 
most  used,  by  almost  common  consent  of  the  profession,  to  reduce  the 
temperature  in  malignant  scarlet  fever,  but  its  use  for  this  purpose  is, 
according  to  my  observations,  fir  from  satisfactory.  To  obtain  its  anti- 
pyretic action  it  must  be  adiniiiistered  in  large  doses,  and  if  any  of  the 
quinine  salts  in  ordinary  use  be  administered  by  the  mouth  in  sufficient 
quantity,  they  are  apt  to  be  vomited.  To  a  child  of  five  years  five  grains 
should  be  administered  twice  daily  by  the  mouth,  or  ten  grains  of  a 
soluble  salt,  as  the  bisulphate,  may  be  given  per  rectum,  dissolved  in  a 
little  warm  Avater.  ATTmihTsfered  per  rectum,  it  is  frccpiently  not  re- 
tained unless  held  for  a  time  by  a  napkin.  A  considerable  jiroportion 
of  the  malignant  cases  are  attended  by  not  only  irritability  of  the 
stomach,  already  alluded  to,  but  by  diarrhoea,  so  that  quinine,  if  admin- 
istered at  all,  should  be  employed  hypodermically.  The  double  salt  of 
quinia  and  urea  answers  for  this  purpose,  as  it  is  very  soluble  in  water 
and  does  not  produce  inflanimation  of  the  connective  tissue.  When  the 
antipyretic  doses  of  quinine  are  discontinued,  this  agent  may  be  pre- 
scribed as  a  tonic  in  the  doses  recommended  fjr  the  treatment  of  mild 
scarlet  fever. 

In  severe  cases  with  frequent  and  rapid  pulse  in  whic-h  ante-mortem 
heart-clots  are  a])t  to  occur,  the  ammonium  carbonate  is  often  useful.  It 
should  be  dissolved  in  water  and  given  in  milk,  in  as  large  doses  {is  five 
grams  cygry  hour  or  second  hourTo  a  child  of  five  years.  It  aids  in 
producing  stronger  contraction  of  the  cardiac  muscular  fibres,  and  thus 
diminishes  the  danger  of  the  formation  of  thrombi.  Ten-drop  doses  of 
the  aromatic  spirits  of^ammonia  may  be  employed  instead  of  the  carbo- 
nate, given  in  sweetened  water.  It  is  especially  useful  if  the  stomach 
be  irritable. 

In  severe  cases  attended  bv  considerable  angina  and  foul  and  offensive 
secretions  upon  the  faucial  surface  an  antiseptic,  as  boracic  acid  in  small 


ANTISEPTIC    TREATMENT.  253 

r^uantity,  should  be  adfled  to  the  potash  and  iron  mixture  recommended 
above.  If  no  drink  be  aUowed  for  a  few  minutes  after  the  dose,  so  as 
not  to  wash  it  too  soon  from  the  fauces,  the  antiseptic  effect  is  more  cer- 
tainly produced.  Those  old  enough  should  be  directed  to  hold  the  medi- 
cine for  a  moment  like  a  gargle  in  the  throat  before  swallowing  it.  I 
employ  boracic  acid  by  preference,  as  in  the  following  formula : 

K. — Acid,  boracic. ^ss.  /  ; 

P<jlass.  chlorat.         ......  r^\\.  |  . 

Tr.  ferri  chluridi      ......  f^ij.  1/ 

GlyceririiB, /-i-if^i 

Synipi \''     ^J' 

Aquae        ........  f  5 'j — Misce. 

Sig. — Give  one  teaspoonful  every  two  hours  to  a  cliild  of  five  years. 

More  minute  directions  will  presently  be  given  for  the  treatment  of 
the  pharyngitis  when  we  speak  of  the  complications. 

Alcoiiol,  whether  administered  in  one  of  the  stronger  Avines,  as  sherry, 
or  in  whislcey  or  brandy,  is  a  most  useful  remedy  in  scarlet  fever,  and  is 
indeed  indispensable  in  all  grave  cases  which  are  attended  by  fegblfi-Capil- 
lary  circulation  aiid  evidences  of  prostration.  Milk  is  also  the  best 
vehicle  for  this  agent.  The  wine-whey  or  milk-punch  should  be  given 
every  hour  or  second  hour.  In  scarlet  fever,  as  well  as  diphtheria,  con>- 
paratively  large  doses  are  required,  as  a  teaspoonful  of  the  stimulant 
every  hour  or  second  hour  for  a  child  of  five  years. 

During  convalescence  tiie  hygienic  treatment  already  described  is 
important.  Nutritious  diet  and  a  moderate  amount  of  alcoholic  stimu- 
lants are  required,  while  the  patient  is  kept  indoor  and  protected  from 
currents  of  air  as  long  as  desquamation  is  occurring.  More  or  less 
anaemia  is  present  in  most  convalescent  patients,  so  that  a  mild  tonic 
containing  iron  will  aid  in  restoring  the  health.  Eli.xir  of  calisaya-bark 
and  iron;  jireparations  of  beef,  iron,  and  wine,  or  the  following  pre- 
scription, will  be  fjund  useful  under  such  circumstances: 

li  . — Ferri  et  ammon.  citrat. 

Ammon.  carboiiiii.   ......  fiu  .'^•'■^-.^j- 

Syrupi i"^].' 

Aquae f.S'j- — Misce. 

SiiT- — Dose,  one  or  two  toaspnonfuls,  according  t')  th(!  age,  in  water,  every  second 
or  lliirl  hour. 

Antiseptic  Treatment. — It  is  still  to  be  determined  whether  or  to 
what  extent  antiseptics,  administered  internally,  antagonize  and  control 
the  scarlatinous  poison,  and  arc,  therefore,  curative  of  scarlet  fever. 
The  most  important  agent  of  this  class,  carbolic  acid,  can  only  be  eni- 
j)loyed  in  small  doses,  for  a  dose  much  exceeding  a  drop  for  a  child,  or 
even  exceeding  a  fractional  ]»art  of  a  drop  for  a  young  child,  might  ))ro- 
duce  poisonous  symptoms.  Carbolic  acid  i.s  a  cardiac  and  arterial  seda- 
tive, and  it  appears  to  reduce  temperature.  Intrauterine  injections  of 
carboli/.cd  water  in  the  treatment  of  puerperal  fever  are  known  to  reduce 
temp?rature,  even  when  there  is  no  septic  matter  in  the  uterus  to  be 
disinfected  and  washeil  awav,  as  in  a  case  related  to  me  in  which  the 


254  SCARLET    FEVER. 

fever  proved  to  be  due  to  measles.  It  is  not  improbable  that  the  anti- 
pyretic action  in  patients  of  this  class  who  have  no  septic  substance 
within  the  uterus  is  due  largely,  if  not  mainly,  to  the  absorption  of 
carbolic  acid  from  the  uterine  surface  and  its  sedative  action  on  the 
vascular  system.  Whether  this  agent,  so  highly  extolled  by  Declat, 
and  to  which  I  have  alluded  in  a  preceding  page,  can  be  safely  employed 
in  doses  large  enough  to  be  efficient  and  curative  will  be  determined  by 
future  observations.  The  same  remark  is  applicable  to  the  sulphocar- 
bolate  of  sodium,  whose  antiseptic  action  is  supposed  to  be  due,  as 
already  stated,  to  the  liberation  of  carbolic  acid  in  the  system.  Since 
boracicacid  does  not  seem  to  have  any  deleterious  action,  this  agent  has 
been  administered  to  most  of  my  scarlatinous  patients  during  the  last 
year,  in  addition  to  the  older  and  better  known  remedies,  and  with  a 
very  small  percentage  of  deaths.  What  may  be  the  result  in  a  more 
severe  type  of  the  disease  remains  to  be  seen. 

Treatment  op  Complications  and  Sequelae. — Local  measures 
designed  to  diminish_or_cure  the  phaj-yngitis  are  important  in  all  but 
the  mildest  cases.  They  are  more  especially  required  in  the  anginose 
variety  and  in  those  not  infrequent  cases  in  which  diphtheria  complicates 
scarlatina.  Formerly  it  was  necessary,  in  making  applications  to  the 
fauces,  to  employ  the  brush  or  probang  for  those  too  young  to  use  the 
gargle,  but  hand-atomizers,  as  Richardson's  or  Delano's,  which  are  now 
in  common  useTaHonTa  quick  and  easy  method  for  making  such  appli- 
cations. Six  or  eight  compressions  of  the  bulb  of  a  good  atomizer  are 
sufficient  to  cover  the  fiuces  with  the  spray.  Those  hand-atomizers  in 
the  shops  which  have  slender  metallic  points  are  apt  to  prick  the  buccal 
surface  and  cause  bleeding  if  the  child  resist  and  toss  the  head.  To 
prevent  this,  I  am  in  the  habit  of  directing  India-rubber  tubing  to  be 
drawn  over  the  point  in  such  a  way  as  not  to  obstruct  its  action.  The 
following  will  be  found  useful  mixtures  for  the  atomizer :  For  ordinary 
cases, 

R. — Acidi  earbolici    3  s?,  vel.  Acid,  boracic.    jij. 

Potass,  chlorat.   ^  ij. 

Glycerinte  ^.I'i- 

Aquae  ^S^'j- — Misce. 

If  the  surface  of  the  throat  be  covered  by  foul  secretions, 

R. — Acidi  carbolic!    . 
Potass,  chlorat.   . 
Glycerinse  . 
Aquae  calcis 

Or  else, 

R. — Tine,  ferri  chloridi 
Acidi  sulphurosi 
Pota?s.  chlorat.  . 
Glycerinae. 
Aquae 

If  diphtheritic  exudation  complicate  the  scarlatinous  angina,  or  the  sur- 
face of  the  throat  in  consequence  of  ulceration  or  necrosis  present  an 


TREATMENT    OF    COMPLICATIOXS    AXD    SEQUELAE.       20D 

appearance  like  that  in  diphtheria  when  the  exudation  begins  to  soften, 
being  foul,  jagged,  of  a  dirty  brown  appearance  from  dead  maUer  and 
fetid  secretions,  those  mixtures  for  spra^^ing  the  throat  will  be  found 
useful  which  are  recommended  in  our  remarks  relating  to  the  local 
treatment  of  diphtheria. 

The  following;  mixtures  are  also  beneficial  for  local  treatment  Avhen  the 
faucial  surfiice  is  foul  and  offensive  from  the  exudations  and  secretions. 
They  should  be  applied  by  a  large  camel's-hair  pencil  every  three  to  six 
hours : 

R. — Acidi  carbolici  .         ....     gtt.  x. 

Liq.  ferri  subiulphatis      .         .         .     f.^ij. 

Glyceriiise  .....     f3J. — Misce. 

R. — 01.  citronelli      .         .         .         .         .     ptt.  vj. 

Iodoform  .         .         .         .         .         .      ^ij. 

Vaseline    ......     3SS. — Mi?ce. 

In  all  cases  of  scarlatinous  pharyngitis  sufficiently  severe  to  require 
special  treatment,  cool  applications  should  be  made  over  the  neck  from 
ear  to  ear,  as  by  two~thicknesses  of  njuslin  frequently  squeezed  out  of 
cold  water,  or  by  the  elongated  India-mbjjer  bag  already  recommended 
in  our  remarks  relating  to  methods  to  reduce  temperature. 

In  the  first  days  of  scarlet  fever  the  coryza  is  slight,  and  no  dis- 
charge from  the  nostrils  occurs,  so  that  no  local  treatment  is  required  ; 
but  before  the  termination  of  the  malady,  in  cases  of  ordinary  gravity,  a 
nasal  discharge  usually  supervenes,  producing  more  or  less  redness  and 
eitcnrjating  the  upper  lip.  Moreover,  in  localities  where  diphtheria 
occurs,  if  this  malady  complicate  scarlet  fever,  it  is  apt  to  affect  the 
nostrils  at  the  sajjieJtiine  that  the  fauces  are  invaded.  These  conditions 
require  local  treatment  of  tlie  narcs.  It  should  be  remembered  that 
the  Schneiderian  membrane  is  midway  in  sensitiveness,  as  it  is  in  loca- 
tion, between  the  conjunctival  and  buccal  surfaces,  and  is  readily  irri- 
tated by  strong  applications.  Medicinal  applications  made  to  it  must 
be  much  milder  than  those  which  the  fauces  tolerate.  They  should 
always  be  applied  warm,  and  a  teaspoonful  of  any  mixture  properly 
employed  is  sufficient  for  each  nostril  at  one  sitting.  The  applications 
should  usually  be  made  every  two  or  four  hours,  according  to  the 
gravity  of  the  case  and  the  amount  of  discharge.  The  best  instrument 
for  this  purpose  is  a  small  syringe  of  glass  or  brass  with  curved  neck 
and  bulbous  tip.  The  child's  head  should  be  thrown  back  and  the 
piston  depressed  rapidly,  so  as  thoroughly  to  wash  out  the  nasal  cavity. 
The  application  can  also  be  made  through  an  atomizer  with  a  rounded 
tip  or  a  tip  covered  by  rubber  tubing.  The  following  is  a  useful  pre- 
scription : 

H  . — Acidi  carbolici  ........      ^ss. 

Sodii  chloridi  .         .         .         .         .         .         .      zij. 

Aqiiaj 6j. 

The  substitution  of  2  or  3  drachms  of  boracic  acid  in  place  of  the 
carbolic  acid  makes  a  nicer  preparation.  If  the  diphtheritic  pseudo- 
membrane  appear  in  the  nares,  the  officinal  lime-water,  injected  every 
hour  or  second  hour,  is  beneficial  in  consequence  of  its  solvent  action  on 
pseudo-membranes. 


256  SCARLET    FEVER. 

It  is  evident,  from  what  lias  been  stated  above,  that  the  condition  of 
tlie  ear  should  be  closely  observed  in  and  after  scarlet  fever.  If  the 
patient  have  earacji^e.  considerable  relief  may  be  obtained  in  the  com- 
mencement by  drop.ping  a  few  drops  of  laudanum  and  sweet_  oil  into 
the  ear  and  covering  it  by  some  Ijot^applieation,  either  dry  or  moist, 
which  will  retain  the  heat.  A  light  bag  containing  common  table-salt, 
heated,  or  dry  and  hot  chamomile  flowers,  will  also  answer  the  purpose. 
Water  as  hot  as  can  be  well  tolerated  dropped  into  the  ear  or  allowed 
to  trickle  from  a  fountain  syringe,  so  as  to  fill  the  ear,  is  also  very  bene- 
ficial in  allaying  the  pain.  If  a  few  drops  of  laiidanum  be  added,  it  is 
more  useful.  If  the  pain  be  not  quickly  relieved,  a  leech  should  be 
applied  at  the  base  of  the  tragus.  (X  D.  Pomeroy,  an  experienced 
aurist  of  New  York,  says:  "Leeching  employed  at  the  right  time 
rarely  fails  to  subdue  the  pain  and  inflammation.  The  posterior  face 
of  the  tragus  is  ordinarily  the  best  place  for  ap])lying  the  leech,  but  it 
may  be  applied  in  front  of  the  ear  or  behind,  wherever  the  tenderness 
on  pressure  is  greatest.  In  my  opinion,  paracentesis  may  fretpiently  be 
rendered  unnecessary  by  the  timely  use  of  one  or  two  leeches  applied  to 
the  meatus."' 

If  the  otitis  continue,  as  shown  by  pain  in  the  ear,  of  which  chil- 
dren old  enough  to  speak  bitterly  complain,  and  which  causes  those  too 
young  to  speak  to  press  their  fingers  into  or  against  their  ears,  this  in- 
flammation should  not  be  neglected,  as  it  may  involve  serious  conse- 
quences. Multitudes  of  children  have  had  permanent  impairment  or 
even  loss  of  hearing,  with  caries  or  necrosis  of  the  Avails  of  the  middle 
ear  and  of  the  mastoid  cells,  which  might  have  been  prevented  by 
prompt  and  skilful  management  of  the  ear  in  the  early  stage  of  the  in- 
flammation. If,  therefore,  the  otitis  continue  without  mitigation  of 
pain  after  the  above  measures  have  been  employed,  paracentesis  of  the 
drumhead  is  probably  required.  The  following  directions  for  perform- 
ing this  operation,  which  will  be  useful  to  country  practitioners  who  may 
not  be  able  to  obtain  the  assistance  of  a  specialist,  are  from  the  pen  of 
Pomeroy :  "  The  forehead  mirror  should  be  worn,  in  order  to  leave  the 
hands  free  to  operate  by  either  artificial  or  day  light.  A  good-sized 
speculum  is  introduced  into  the  meatus.  Then  an  ordinary  broad 
needle,  about  one  line  in  diameter,  with  a  shank  of  aljout  two  inches, 
such  as  oculists  use  for  puncturing  the  cornea,  should  be  held  between 
the  thumb  and  fingers,  lightly  pressed,  so  as  not  to  dull  delicate 
tactile  sensibility.  The  part  being  well  under  light,  the  most  bulging 
portion  of  the  membrane  should  be  lightly  and  quickly  punctured  with 
a  very  slight  amount  of  force.  The  posterior  and  superior  portion  of 
the  membrane  is  the  most  likely  to  bulge.  Tlie  chord;^  tympani  nerve 
ordinarily  lies  too  high  up  to  be  Avounded.  The  ossicles  are  avoided  by 
selecting  a  posterior  portion  of  the  membrane.  After  puncture  the  ear 
should  be  inflated  by  an  ear-bag  Avhose  nozzle  is  inserted  into  a  nostril, 
both  nostrils  being  closed,  so  as  to  force  the  fluid  from  the  tympanum. 
The  puncture  may  need  to  be  repeated  at  intervals  of  a  day  or  tAvo, 
provided  that  the  pain  and  bulging  return." 

Albert  II.  Buck,  of  Ncav  York,  in  a  highly  instructive  paper  read 
before  the  International  Medical  Congress  in  1876,  Avi'ites  as  follows  of 


treat:m:ext   of  complicatioxs  axd  sequelje.     257 

paracentesis  of  the  membrana  tympani  in  scarlatinous  otitis:  '"In  this 
one  slight  operation,  Avhich  in  itself  is  neither  dangerous  nor  very  pain- 
ful, lies  the  power  to  prevent  the  whole  train  of  disagreeable  and  dan- 
gerous symptoms.'  Buck  relates  an  insti'uctive  example:  The  age  of 
the  patient  was  three  years,  and  the  earache  had  been  complained  of 
only  about  twenty-four  hours.     ''Toward  morning,"  says  he,   "  I  was 

sent  for,  as  the  pain  had  become  constant An  examination  Avith 

the  speculum  and  reflected  light  showed  an  cedematous  and  bulging 
membrana  tympani  (posterior  half),  the  neighboring  parts  being  very 
red,  though  as  yet  but  little  swollen.  In  the  most  prominent  portion  of 
the  membrane  I  made  an  incision  scarcely  three  millimetres  (one-tenth 
inch)  in  length,  and  involving  simply  the  different  layers  of  the  mera- 
bnina  tympani.  This  was  almost  immediately  followed  by  a  watery 
discharge  (without  the  aid  of  inflation),  which  ran  down  over  the  child's 
cheek.  At  tlie  end  of  three  or  four  minutes  the  child  had  ceased 
crying,  and  in  less  than  a  quarter  of  an  hour  she  was  fast  asleep.  At 
first,  the  discharge  was  very  abundant  and  mjiinly  watery  in  character, 
but  it  steadily  diminished  in  quantity  and  became  thicker,  till  finally, 
on  the  fourth  day,  it  ceased  altogether.  On  the  tenth  day  the  most 
careful  examination  of  the  car  could  net  detect  any  trace  of  cither  the 
inflammation  or  the  artificial  opening."  The  ear  had  jjrobably  been 
saved  from  ulceration  of  the  drum  membrane,  long-continued  suppura- 
tive otitis,  and  perhaps  permanent  impairment  of  hearing. 

When  an  opening  has  been  made  in  the  membrana  t3nnpani  either  by 
incision  or  ulceration,  it  is  advisable  in  some  instances  to  inflate  the  tym- 
panum by  Politzers  method,  which  has  been  alluded  to  above.  The 
nozzle  of  an  India-rubber  bag.  with  a  flexible  tube  attached,  is  introduced 
into  the  no<tiil  on  the  affected  side,  and  both  nostrils  are  compressed 
against  it.  The  patient  fills  his  mouth  with  water,  which  he  swallows 
at  a  given  signal,  as  after  the  words  one,  two,  three,  spoken  by  the  ope- 
rator. During  the  act  of  swallowing,  which  opens  the  Eustachian  tube, 
the  rubber  bag  is  forcibly  compressed,  which  forces  the  air  along  the 
tube  into  the  middle  ear  and  facilitates  the  escape  of  the  pent-up  secre- 
tions in  the  tympanic  cavity. 

If  the  otitis  have  continued  unchecked  by  treatment  until  the  secre- 
tions within  it,  after  days  and  nights  of  suffering,  have  escaped  by 
ulceration  through  the  drumhead,  the  opportunity  for  prompt  and  certain 
cure  is  passed.  kStill,  the  patient  under  these  circumstances  may  ([uickly 
recover,  or  there  may  b(.'  the  other  alternative  described  above,  in  which 
the  eir  is  badly  damaged  and  chronic  inllannnation  established  in  the 
walls  of  the  tympanum,  giving  rise  to  an  offensive  otorrhoea.  In  this 
state  of  the  ear  internal  remedies  are  indicated,  such  as  surgeons  employ 
in  suppurative  inflammations  of  bone  occurring  in  other  parts  of  the 
system.  Cod-liver  oil  and  iodide  of  iron  are  re(juired,  esj)ecially  by 
));itient3  of  strumous  di;ithesis,  the  object  being  to  promote  a  more 
healthy  state  of  system,  so  as  to  prevent  extension  of  the  inflammation 
and  facilitate  the  healing  process.  Carbolized  solutions,  as  the  following, 
yringo<l  warm  into  the  ear  in  which  otorrhoea  is  occurring,  are  useful 
in  promoting  cleanliness  and  increasing  the  comfort  of  the  patient: 


258  SCARLET    FEVER. 

R. — Acidi  carbolici z^s- 

Glycerinae    .         .         .         .         .         .         .         .     fsij. 

Aquic  .........     f5iv- — Misce. 

But  recently  a  much  more  effectual  curative  agent  for  local  treatment 
has  been  discovered  in  boracic  acid,  by  the  use  of  which  the  discharge 
more  quickly  diminishes  and  the  condition  of  the  ear  more  certainly  and 
r.ipidly  improves  than  by  the  use  of  the  carbolized  mixtures.  When  the 
inflammation  is  recent  and  the  ear  sensitive  and  painful,  the  following 
prescription  should  be  used: 

R  — Acidi  boraciei oij^s. 

Morphi;«  sulphat.         .         .         .         .         .         .     gr  j. 

Glycerinae, 

Aquae afi  f^j. — Misce. 

Sig. — Drop  one  to  three  drops  into  tlie  ear  three  times  dialy. 

If  the  acute  stage  of  the  otitis  have  passed,  with  fever  and  pain,  and 
no  tenderness  be  present  on  pressure,  the  following  prescription,  which 
causes  too  much  pain  in  the  acute  stage,  Avill  be  found  useful  to  check 
the  inflammation  and  otorrhoea  and  restore  a  healthy  state  to  the  granu- 
lating surface: 

R. — Acidi  boraciei     ........  S'jss. 

Alcohol. 

Aquffi  . an  f 3J. 

Sig. — Drop  one  to  three  drop?  into  the  ear  three  times  daily. 

The  beneficial  effects  observed  from  the  use  of  boracic  acid  in  aural 
surgery  have  given  it  nearly  the  same  position  as  a  curative  agent  to 
diseases  of  the  ear  Avhich  atropine  holds  to  diseases  of  the  eye.  Recently, 
aurists  are  employing  finely  triturated  powder  of  boracic  acid  dusted 
into  the  ear.  The  patient  lies  upon  the  side  with  the  affected  ear 
uppermost.  The  ear  is  thoroughly  cleaned  by  syringing  with  tepid 
water,  and  by  means  of  a  little  scoop  made  of  stiff  paper  or  pasteboard 
or  the  segment  of  quill  as  much  of  the  powder  is  introduced  into  the 
ear  as  Avill  cover  a  five-cent  silver  piece.  By  working  the  ear  it 
descends  to  the  drumhead.  I  can  bear  witness  to  its  efficacy  in  the 
otorrhoea  of  children  when  it  is  used  in  this  manner  three  times  daily. 

The  following  astringent  has  also  been  employed  with  good  results  for 
the  otorrhoea  resulting  from  scarlet  fever  as  well  as  from  other  causes: 

R. — Zinci  sulphatis, 

Aluminis  .         .         .         .         .         .         .         .     aa  gr.  v. 

Aquae f^j. — Miscc. 

A  few  drops  of  this  should  be  dropped  into  the  ear,  or,  if  the  ear  be 
sensitive  and  painful,  five  drops  should  be  added  to  a  teaspoonful  of 
warm  water  and  dropped  or  syringed  into  the  ear. 

But  in  recent  times,  aurists  have  discovered  a  remedy  superior  to 
the  above  in  iodoform,  the  action  of  which  is  safe  and  efficient  for 
protracted  otorrhoea  with  granulations,  and  it  is  superseding  to  a  great 
extent  the  agents  heretofore  used»  in  the  treatment  of  this  disease.  The 
ear  should  first  be  thoroughly  cleaned  by  syringing  with  warm  water 


THE  AT  ME  XT    OF    COMPLICATION'S    AND    SEQUEL.E.      259 

and  dried,  and  iodoform,  to  which  a  little  balsam  of  Peru  is  added  to 
mask  the  disao-reeable  odor,  should  be  pressed  down  to  the  bottom  of  the 
auditory  canal  by  any  convenient  instrument.  It  is  anodyne,  astrinii;ent, 
and  disinfectant,  and  should  be  employed  in  a  dry  state  in  considerable 
quantity. 

The  sequelre  of  otitis  media,  such  as  granulations  sprouting  out  from 
the  drumhead,  some  of  which  may  be  of  large  size,  and  are  known  as 
])olypi,  may  require  treatment  by  the  aurist.  A  polypus  may  some- 
times be  removed  by  the  forceps,  or  better  by  the  snare.  Polypi  not 
large  and  favorably  located  can  sometimes  be  cured  by  an  astringent 
powder,  as  iodoform,  sulphate  of  zinc,  or  alum,  or  by  applying  the  liquid 
subsulphate  of  iron.  The  otitis  externa  produced  by  the  irritating  dis- 
charge which  flows  from  the  middle  ear  soon  disappears  when  the  flow 
ceases. 

The  renal  affection,  which,  as  Ave  have  seen,  so  often  commences  in 
the  declining  period  of  scarlet  fever,  or  during  convalescence  in  mild  as 
well  as  severe  cases,  is  frequently  more  dangerous  than  the  primary 
disease.  It  largely  increases  the  percentage  of  deaths.  A  clear  appre- 
ciation of  its  therapeutic  requirements  is  important,  since  by  judicious 
treatment  many  recover  who  would  inevitaljly  be  sacrificed  by  improper 
measures.  The  family  should  be  informed  that  the  danger  from  scarlet 
fever  does  not  cease  with  the  decline  of  the  eruption,  and  that  the  kid- 
neys may  become  seriously  affected  by  too  early  exposure  of  the  patient 
to  currents  of  air  or  sudden  changes  of  temperature,  by  which  cutaneous 
transpiration  is  checked.  lie  should,  therefore,  be  kept  indoor  in  a 
comfortaljle  and  uniform  temjieratiire  three  or  four  weeks  after  the  ter- 
mination of  the  fever,  until  desquamation  has  entirely  ceased  and  the 
new  epiderm  is  sufficiently  thick  and  firm  to  protect  the  surfixce.  During 
the  changeable  temperature  of  the  autumnal,  winter,  and  spring  months 
even  longer  confinement  at  home  may  be  advisable. 

The  nephritis  and  conse(|uent  al1>uniinuria  antedate  by  some  days  the 
occurrence  of  dropsy,  and  a  physician  should  never  discharge  a  scar- 
latinous patient  without  one  or  more  examinations  of  his  urine.  When 
his  visits  cease  the  nurse  should  be  instructed  to  make  the  examinations 
by  heat  and  nitric  acid  during  the  ensuing  month,  and  if  any  evidence, 
however  slight,  appear  that  the  kidneys  are  involved,  he  should  bo 
notified,  in  order  that  appropriate  treatment  may  be  immediately  com- 
menced. Early  and  correct  treatment  of  the  nephritis  is  atten<le(l  by 
much  better  results  than  delayed  treatment,  and  many  more  patients 
are  doubtless  now  saved  than  in  former  times,  when  little  attention  was 
given  to  the  state  of  the  kidneys  until  dropsy  or  other  prominent  symp- 
toms appeared.  I  have  found  no  mother  or  nurse  so  ignorant  that  she 
could  not  ])roperly  employ  the  test  of  nitric  acid  and  heat,  and  if  she  be 
solicitous  for  the  weltiire  of  the  child,  she  Avill  not  hesitate  to  carry  out 
the  directions  and  immediately  notify  the  physician  if  the  tests  employed 
produce  the  least  cloudiness  or  turbidity  of  the  urine. 

The  patient  as  soon  as  nephritis  commences,  as  shown  by  the  state  of 
the  urine,  should  be  put  to  bed  in  a  room  of  warm  and  equable  tempera- 
ture (72°  to  7.')°  F.).  His  diet  shouhl  l)e  liquid,  consisting  of  milk, 
farinaceous  food,  and  a  moderate  (quantity  of  animal  brotlis.      He  may 


260  SCARLET    FEVER. 

drink  liquids  freely,  especially  water  not  too  cool,  to  which  spiritus 
j£th,Qjns  nitrosi  is  added.  If  he  be  prostrated  by  the  primary  disease, 
alcoholic  stiuTulants  should  be  allowed. 

The  indications  are  to  rcl_iove  the  h_yj)cr?emic  kidneys  by  diaphoresis 
and  p_in*gation.  To  ))roduce  the  former  the  patient  should  be  immersed 
in  a  A\;arinT)ath  at  about  the  temperature  of  the  body  (1*8°  to  100°),  in 
which,  if  iie^e  quiet  and  comfortable,  he  should  remain  from  fifteen  to 
tAventy  minutes,  but  if  restless  and  frightened  by  the  water  a  less  time, 
after  which  he  should  be  placed  in  a  warm  bed  and  well  covered  by 
blankets.  If  perspiration  result,  the  bath  has  been  useful,  and  it  may 
be  employed  in  grave  cases  two  or  ,th.ree^tiines_  daily .  If  perspiration 
do  not  result,  it  may  be  produced  by  surrounding  the  body  either  by 
hot  dry  or  moist  air.  Hot  dry  air  may  be  produced  by  burning  alcohol 
iiiaTaln  layer  upon  a  plate  under  a  chair  upon  which  the  patient  sits 
while  he  is  surrounded  by  a  blanket,  or  he  may  be  covered  in  bed  and 
the  hot  air  introduced  under  the  bedclothes.  In  New  York  a  con- 
venient apparatus  is  used  for  this  purpose,  consisting  of  a  small  sheet- 
iron  pipe  enclosed  in  a  small  box  of  the  same  material.  The  box  is  in 
the  form  of  a  trunk,  with  a  handle  for  convenience  in  carrying,  and  the 
lower  end  of  the  pipe,  which  extends  nearly  to  the  floor,  contains  an 
alcohol  lamp.  Hot  moist  air  may  be  produced  by  placing  against  the 
patient  bottles  of  hot  WitST  surrounded  by  towels  wrung  out  of  water. 
The  steam  arising  from  them  and  enveloping  the  body  and  limbs  produces 
a  prompt  sudorific  effect.  There  is  in  use  in  this  city,  in  the  treatment 
of  these  and  similar  cases  requiring  diaphoresis,  a  convenient  apparatus 
for  generating  steam.  It  consists  of  a  cylinder  pierced  with  holes  for 
the  admission  of  air  and  containing  a  spirit  lamp, -over  which  is  a  pan  or 
pail  holding  a  little  water.  The  patient,  nearly  naked,  is  placed  in  a  chair 
with  the  apparatus  underneath,  and  is  covered  by  a  blanket,  so  that  the 
steam  surrounds  the  body.  This  gives  rise  to  free  perspiration,  which 
continues  after  the  patient  is  placed  in  bed.  This  treatment  should  be 
repeated  one  or  more  times  daily,  according  to  the  gravity  of  the  case. 

The  sudorific  effect  of  the  treatment  by  external  warmth  described 
above  should  be  aided  by  employing  diaphoretics.  Those  which  liave 
been  most  used  are  the  acetates  of  auiinonium  and  potass  jinn,  the  bitar- 
trate  and  citrate  of  potassiumTand  spiritus  octlieris  nitrosi.  If  employed 
when  the  surface  is  cool,  they  act  rather  as  diuretics  than  diaphoretics. 
These  agents,  being  simple  in  their  action  and  without  deleterious  effect, 
may  be  given  frequently  and  in  large  proportionate  doses  for  the  age. 

But  lately  a  diaphoretic  which  far  surpasses  these  in  efiiciency  has 
been  discovered  in  pilocarpine,  the  active  princi])le  of  jaborandi.  Being 
soluble  in  water  and  tasteless,  it  is  easily  administered,  and  is  retained 
when,  on  account  of  the  ursemic  poisoning  present  in  scarlatinous 
nephritis,  the  stomach  is  irritable  and  other  medicines,  as  digitalis,  are 
rejected.  Ether  may  be  employed  with  it,  or  the  amount  of  alcoholic 
stimulant  may  be  increase<l  at  the  time  of  its  exhibition  in  order  to  guard 
against  any  depressing  effect.  To  a  child  of  two  years  one-fortieth  to 
one-twentieth  of  a  grain  may  be  given  every  six  hours  by  the  mouth.  It 
may  also  be  employed  hypodermically,  as  one-twentieth  of  a  grain  to  a 
child  of  five  years.     It  has  both  a  diaphoretic  and  diuretic  action,  while 


TREATMENT    OF    COMPLICATIONS    AND    SEQUELAE.      261 

it  stimulates  both  the  salivary  and  raucous  secretion^;.  According  to 
one  observer,  an  adult  when  fully  under  the  influence  of  pilocarpine 
secretes  from  one  pint  to  one  quart  of  saliva  Avithin  two  hours,  and 
Levden  reports  a  cne  of  diphtheritic  nephritis  in  which  the  quantity 
of  "urine  rose  from  half  a  pint  to  five  pints  daily.  But  its  most  prompt 
and  certain  action  is  upon  the  sweat-glands.  Hirschfeldor  spe.iks  of  its 
beneficial  action  in  relieving  various  forms  of  dropsy,  and  adds:  "In 
one  morbid  condition  of  the  kidney,  however,  jaborandi  is  the  remedy 
par  excellence,  and  that  is  the  acute  parenchymatous  nephritis  which 

frequently  folloAvs  scarlatina This  disease  heals  spontaneously 

if  the  danger  that  threatens  life  from  reduction  of  the  urine  and  from 
the  effusions  of  fluid  into  the  cavities  of  the  body  be  averted.  In  this 
disease  jaborandi  works  wonders."  I  have  also  found  it  an  invaluable 
agent  when  the  older  remedies  failed  and  death  seemed  imminent.  The 
fullowing  cases,  in  which  the  beneficial  action  of  this  agent  was  apparent, 
occurred  in  my  practice  : 

Case  8. — G ,  male,  aged  five  years  and  six  montlis.  sickened  with 

scarlet  fever  on  June  2,  1882.  It  be^an  with  vomiting,  and  was  attended 
by  a  degree  of  febrile  movement  which  indicated  an  attack  of  ratlier 
more  than  the  average  gravity.  The  fauces  at  (me  time  exhibited  a 
slight  exudation  like  that  of  diphtheria.  In  tlie  declining  stage  of  the 
mahidy  rheumatic  pain  and  tenderness  occurred  in  the  wrist  and  finger- 
joints,  but  not  in  those  of  the  lower  extremities.  The  case,  however,  pro- 
gressed favorably,  and  during  the  convalescence  mv  attendance  ceased. 
On  June  24th  my  attention  was  again  called  to  the  child,  when  the  urine 
was  found  to  be  scanty  and  very  albuminous.  External  measures,  such 
as  are  described  in  the  foregoing  pages,  were  employed,  and  the  infusion 
of  diiritalis  with  potassium  acetate  ordered  to  be  given  every  three  hours, 
but  this  medicine  was  for  the  most  part  vomited.  The  bowels  were  kept 
open  by  jalap  and  the  potassiunx  hitartrate.  The  urine,  however,  con- 
tiinie  I  scanty,  and  on  June  28th  severe  convulsions  occurred.  At  this 
tiuK!  the  (piantity  of  urine  was  only  f.sij  in  twenty-four  hours.  The  pulse 
in  the  convulsions  was  quick  and  feeble,  the  skin  very  hot,  and  the  axil- 
lary temp.  103'.  The  eclampsia  continued  one  hour,  and  was  con- 
trolled by  large  and  repeateil  doses  of  bromide  of  potassium,  aided  by 
clysters  of  five  grains  of  hydrate  of  chloral  in  water.  Muriate  of  pilo- 
carpine wius  now  directed  to  be  given  in  doses  of  one-thirty-second  of  a 
grain  every  three  hours,  dissolve  I  in  cold  water.  This  agent  was  not 
voinife  I,  and  it  must  have  been  given  i)v  the  jiarents  in  the  fright  and 
anxiety  in  larger  or  more  fre«|uent  doses  than  were  directed,  for  on  July 
1st  the  hottle  containing  one  irrain  was  empty.  Free  diaphoresis  resulted 
from  the  pilocarpini.',  and  the  (piantity  of  urine  was  increased.  The 
mother  statcMl  that  the  child  had  taken  onlv  two  doses,  or  one-sixteenth 
of  a  grain,  of  pilocarpine  when  th((  diuretic  effect  was  apparent  and  free 
diaphoresis  also  occurred.  She  also  staled  subse<pientlv  that  the.  (piantity 
of  urine  was  larger  when  the  |)ilocarpine  was  administered  every  third 
hour  than  when  <;iven  at  a  longer  interval.  A  flaxseed  poultice  on  which 
mustard  was  dusted  was  also  appli(!d  over  the  kidneys.  On  June  20th 
the  puls!>-  was  9(5,  temperature  100.5^;  occasional  convulsive  attacks 
occurred,  which  were  readily  controlled  l)y  enemata  of  hydrate  of  chloral. 
On  Jiin(!  .30th  thesym|)toms  were  all  l»etter;  no  more  attacks  of  e(dampsia 
had  occurred,  and   the  urine  was  more  abundant  and  less  albuminous. 


262  SCARLET    FEVER. 

The  mother  remarked  that  the  new  medieiue  (pihicarpiue)  had  settled 
the  stomach  and  increased  the  urine.  The  patient  continued  to  improve, 
and  on  July  4th  the  record  states :  "  Now  takes  the  pilocarpine,  gr.  -^2, 
every  six  hours;  passes  urine  freely  since  yesterday;  has  not  vomited 
since  he  began  to  take  the  pilocarpine;  pulse  lOG,  axilUiry  temp.  99^; 
is  playful  and  takes  milk  freely,  nearly  three  quarts  in  twenty-i'our 
hours,  with  some  farinaceous  food.  Digitalis  with  ])otassium  acetate  is 
also  given  in  occasional  doses."  July  Bth,  pulse  92,  temp.  99^;  per- 
spires much,  and  urine  nearly  normal  in  quantity  and  character. 

Case  9. — Mary  S — ~,  aged  five  years,  on  Dec.  22,  lc582,  presented  the 
svniptoms  of  severe  nephritis.  Her  brother  had  scarlet  fever  two  weelcs 
previously,  and  she  had  sore  throat  at  about  the  same  time,  but  without 
efflorescence;  pulse  9-'^,  temperature  98.5^;  her  urine  higlily  albuminous, 
and  reduced  to  fsiv  in  twenty -four  hours;  bowels  constipated.  Ordered 
a  single  dose  of 

li  . — Hydrarg.  chlor.  mitis  .         ......     gr.  iij. 

Ivu-iii.  podo|)liylli         .......     yr.  J. — ^lisce. 

The  muriate  of  pilocarpine  was  also  ordered,  gr.  -jV,  but  the  patient 
vomited  soon  after  taking  it.  Another  dose  was  retained,  and  was 
followed  by  considerable  perspiration.  Dec.  23d,  had  one  stool  from  the 
powder  of  yesterday.  Has  taken  five  does  of  jnlocarpine,  but  vomited 
after  three  of  them.  Tl^e  last  dose  was  administered  at  10  P.  M.,  and  the 
mother  says  she  "sweat  fearfully"  during  the  night.  The  patient  Avas 
kept  warm  in  bed;  stimulating  poultices  of  mustard  and  flaxseed,  one  to 
sixteen,  were  constantly  in  use  over  the  kidneys,  and  the  pilocarpine  was 
administered  three  or  four  times  a  day.  The  record  for  Dec.  26th  states: 
"Took  the  pilocarpine  four  times  since  yesterday  jnorning,  and  each  dose 
is  followed  by  perspiration  lasting  from  one  to  one  and  a  half  hours; 
quantity  of  urine,  from  fgvj  to  f'sviij  daily;  vomited  twice  yesterday,  not 
to-day;  pulse  104;  temp.  97.75^;  complains  of  frontal  headache;  bowels 
regular ;  has  considerable  salivation.  The  patient  is  warm  in  bed,  and 
the  flaxseed  and  mustard  poultice  over  the  kidneys  is  continued."  Dec. 
28th,  specific  gravity  of  urine  1019:  urine  still  quite  albuminous  and 
containing  blood  corpuscles  and  granular  casts,  also  crystals  of  oxalate  of 
lime.  Dec.  oOth,  takes  gr.  -^V  ])ilocarpiue  twice  daily,  and  occasional 
doses  of  infusion  of  digitalis;  urine  more  abundant;  it  specific  gravity 
1014,  slightly  albuminous,  and  containing  very  few  granular  casts  tind 
blood-corpuscles;  has  lost  its  smoky  appearance  ;  reaction  alkaline;  per- 
spiration slight ;  patient  convalescent. 

In  another  instance,  a  child  of  five  years,  from  three  to  four  weeks 
after  scarlet  fever  was  noticed  to  have  anasarca  of  the  face  and  extrem- 
ities, with  scanty  and  albuminous  urine.  One-tliirty-second  of  a  grain 
of  nmriate  of  pilocarpine  Avas  administered  every  six  liours  without  the 
desired  sudorific  effect.  It  Avas  then  administered  every  four  hours, 
with  an  increase  of  perspiration  and  urination,  so  that  the  nephritic 
symptoms  were  relieved  and  the  patient  apparently  out  of  danger  within 
three  or  four  days. 

In  a  fourth  patient,  a  girl  of  three  years,  having  scarlatinous  nephritis, 
with  symptoms  very  similar  to  those  in  the  last  case,  tlic  administration 
of  one-tAventieth  grain  doses  of  pilocarjjine  in  conjunction  Avith  the  hot- 
air  bath,  Avas  followed  by  increased  perspiration  and  urination,  and  [»ro- 


TREATMENT    OF    COMPLICATIONS    AND    SEQUELS.       263 

gressive  and  rather  rapid  convalescence.  This  child  had  been  taking 
bichloride  of  mercury  in  one-fiftieth  grain  doses,  prescribed  by  a  honioe- 
ojjathic  physician,  without  appreciable  benefit.  It  had  been  for  the  most 
part  vomited. 

Given,  as  in  the  above  cases,  in  moderate  doses  and  with  sufficient 
interval,  pilocarpine  has  never  in  my  practice  had  any  deleterious  effect, 
and  I  regard  it  as  a  very  important  addition  to  the  remedies  for  the 
relief  of  scarlatinous  nephritis.  It  is  apparently  the  most  useful  and 
important  diaphoretic  for  this  disease  which  we  possess. 

Cathartics,  especially  those  of  a  hydragogue  nature,  are  also  very 
beneficial.  Their  action  is  more  certain  than  that  of  most  diaphoretics 
and  diuretics,  and  their  employment  is  imperatively  required  in  severe 
or  dangerous  cases  in  which  it  is  necessary  to  remove  as  soon  as  possible 
the  serum  or  urea  which  endangers  life.  Young  children  or  those  with 
delicate  stomach,  and  those  much  enfeebled  by  the  primary  disease,  may 
take  magnesia,  either  the  citrate  or  the  calcined.  A  good  cathartic  for 
ordinary  cases  is  a  mixture  of  jalap  and  potassium  J)itartrate,  the  pulyis 
ialapce  compositus,  consisting  of  one  part  of  jalap  and  two  of  cream  of 
tartar.  Ten  grains  of  the  mixture  may  be  given  to  a  child  of  five  years, 
and  repeated  according  to  circumstances.  Its  effect  is  increased  by  dis- 
solving a  teaspoonful  of  potassium  bitartrate  in  a  gobletful  of  Avater,  and 
allowing  the  patient  to  drink  from  it.  The  following  is  a  good  cathartic 
in  some  instances,  especially  if  the  stomach  be  irritable,  so  that  the  more 
bulky  and  nauseating  catharties  are  rejected.  Care  should  be  taken  to 
obtain  a  good  article,  as  some  of  the  podopliyllin  of  the  shops  is  not 
reliable : 

R. — Resinse  podi'phylli         .         .         .         .         .         .         .     gjr.  j. 

Sactluiri         .........     ^j. — Misce. 

Ft.  in  chart.  .........     No.  v.-x. 

Sig. — Give  one  powder,  and  repeat  according  to  circumstances. 

In  the  treatment  of  one  of  the  cases  reported  above  it  will  be  recol- 
lected that  the  mild  chloride  of  mercury  was  given  with  the  podopliyllin, 
with  a  good  result. 

After  the  use  of  laxative  agents  the  kidneys,  being  less  congested  on 
account  of  the  diversion  that  has  occurred,  often  begin  to  excrete  urine 
more  freely.  But  if  the  patient  be  an.emic  or  enfeebled  and  the  symp- 
toms are  not  urgent,  it  is  frecjuently  better  to  avoid  active  catharsis,  which 
more  or  less  reduces  the  strength,  and  employ  remedies  of  a  sustaining 
character,  as  in  the  following  ca.se,  which  occurred  in  my  practice :  A 
little  boy,  pallid  and  .scrofulous,  began  to  have  anasarca  after  scarlet 
fever,  chiefly  in  the  scrotum,  accompanied  by  a  moderate  degree  of 
ascites.  Tin;  urine,  which  was  passed  in  nearly  the  normal  (piaiitity, 
contained  albumen,  but  not  in  large  amount.  This  patient  gradually 
and  fully  recovered,  with  no  treatment  except  the  use  of  an  oil-silk 
jacket  over  the  kidneys  and  abdomen  to  promote  dia|)horesis,  and  the 
use  of  iron.  Such  a  patient,  treated  by  the  jKjwcrful  eliiniiiatives  which 
we  employ  for  the  more  urgent  and  robust  cases,  W(juld  ]»robablv  have 
boen  injured  rather  than  benefited.  No  treatment  can  therefore  be 
recommended    in   a   treatise    on   scarlatinous   nephritis    which    will    be 


2(34  SCARLET    FEVER. 

Strictly  applicable  for  all  cases.     Variations  are  demanded  according  to 
the  state  of  the  patient  and  the  form  and  gravity  of  the  disease. 

Diuretics  which  do  not  stimulate  the  kidneys  are  proper  at  an  early  as 
well  as  late  period  of  the  renal  malady,  and  digitalis  is  the  one  usually 
prescribed.  I  do  not  hesitate  to  order  it  from  the  first  day  in  combina- 
tion with  the  acetate  of  potassium.  One  teaspoonful  of  the  infusion  may 
be  given  every  third  hour  to  a  child  of  five  years.  The  following  formula 
is  for  one  of  this  age  in  good  general  condition: 

R . — Potass,  acetatis   .         .         .         .         .         .         .         .       Sps. 

Infus.  digitalis    ........     f5vj, — Misce. 

The  following  formulte  are  recommended  by  Meigs  and  Pepper : 

R. — Potass,  bitart 5;j. 

Spt.  junip.  comp.        .         .         .         ,         .         .         .  f^ij. 

Spt.  iether.  nitros.       .......  f^j. 

Tr.  digitalis lllxv. 

Syriipi         .         .         .         .         .         .         .         .         .  fzv. 

Aqiiaj  .........  f5i.i. — Misce. 

Dose. — One  teaspoonful  every  two  hours  to  a  child  of  two  to  four  years. 

R. — Potass,  acetat 3J. 

Tr.  digitalis .         .     f^ss. 

Syr.  scilhc f^J-'J- 

Syr.  zingib f^v. 

Aqu;B  .......         q.  s.  ad.  1^:5  iij. — Misce. 

Dose. — A  teaspoonful  every  two  or  three  hours  to  childieii  two  or  three 
years  old. 

!^ocal  treatment  is  important.  L.  Thomas,  Romberg,  and  others 
recommend  the  application  of  leeches,  three  or  more,  over  the  kidneys. 
Thomas  says:  ''  In  many  cases  the  abstraction  of  blood  causes  immediate 
and  permanent  relief;  the  fever  and  the  pain  in  the  region  of  the  kidneys 
cease,  the  secretion  of  urine  becomes  augmented,  tlie  albuminuria  lessens 
from  day  to  day,  and  the  moderate  degree  of  dropsy  that  has  been  devel- 
oped disappears."  It  is  only  in  the  more  robust  children,  who  have 
been  but  little  reduced  by  the  primary  disease,  that  leeching  is,  in  my 
opinion,  admissible.  In  the  majority  of  cases  instead  of  de])letion  a 
poultice  slightly  irritating,  so  as  to  cause  redness  of  the  skin,  should  be 
applied  over  the  kidneys,  or  for  older  children,  not  likely  to  be  frightened 
by  the  process,  the  drycups  may  be  applied  daily.  In  subacute  cases, 
not  attended  by  any  alarming  symptoms,  sufficient  redness  may  be  pro- 
duced by  one  of  the  irritating  plasters  which  the  shops  contain,  constantly 
worn. 

Eclampsia,  described  in  the  preceding  pages,  is  produced,  as  we  have 
seen,  during  the  course  of  scarlet  fever  by  the  irritating  effect  of  the 
scarlatinous  poison  upon  the  nervous  centres ;  but,  occurring  after  the 
decline  of  scarlet  fever,  it  is  ordinarily  produced  by  the  retained  urea. 
The  same  remedies  are  required  to  control  the  convulsive  movements  as 
when  they  occur  under  other  circumstances.  The  bromide  of  potas- 
sium should  be  immediately  administered  in  large  and  frecjuent  doses 
Avhenever  eclamptic  symptoms  arise.  During  eclamjisia  a  child  of 
three  years  should  take  five  grains   of  this   agent   every   five   to  ten 


ROTHELN.  265 

minutes  till  the  attack  ceases,  and  then  at  longer  intervals.  The  hy- 
drate of  chloral  is  a  more  powerful  agent,  and  if  the  eclampsia  be  not 
quickly  controlled,  I  commonly  employ  it  per  rectum,  dissolved  in  one 
or  two  teaspoonfuls  of  water.  For  a  child  of  three  to  five  years  five 
grains  should  be  thrown  into  the  rectum  by  a  small  glass  or  gutta-percha 
syringe,  and  retained  by  pressure.  Properly  administered  and  retained, 
it  rarely  fails  to  control  the  eclampsia  within  ten  or  fifteen  minutes. 
Subsequently,  occasional  doses  of  the  bromide  should  be  given  to  prevent 
the  occurrence  of  eclampsia  while  the  measures  described  above  are  being 
employed  to  eliminate  the  uvea. 

Rheumatism,  endocarditis,  and  pericarditis,  arising  as  complications 
or  sequehe,  require  the  treatment  which  is  appropriate  when  they  occur 
under  other  circumstances,'  but  the  remedies  should  not  be  depressing, 
as  the  system  is  already  enfeebled  by  the  primary  disease.  The  rheu- 
matism, if  mild,  usually  abates  in  a  few  days  without  medication,  and 
the  aft'ected  joints  require  only  some  soothing  lotion  and  Support  by  a 
bandage.  The  following  liniment  may  be  applied  upon  muslin  and 
covered  by  cotton  wadding  : 

H. — Acid,  carbolici        .........     frj. 

Tine.  I)elladi>nna3  .........     f  *j. 

01.  camphorali       .         .         .         .         .         .         .         .         .     f  3  ij. 

If  the  rheumati.sm  be  severe  and  affect  several  joints,  the  sodium  salicy- 
late should  be  prescribed,  as  in  the  idiopathic  disease,  with  an  occasional 
opiate  to  j)rocure  rest. 

Endocarditis  and  pericarditis  require  rest  in  the  horizontal  position, 
avoidance  of  all  excitement,  the  use  of  the  tincture  or  infusion  of  digi- 
talis or  of  the  fluid  extract  of  convalaria  to  procure  a  slow  and  steady 
action  of  the  heart.  Three  drops  of  the  tincture  of  digitalis  or  five 
minims  of  the  fluid  extract  of  convalaria  may  be  given  every  four  hours 
to  a  child  of  five  years.  The  same  external  measures  should  be  employed 
as  in  acute  pleuritis.  I  prefer  the  application  of  a  thin  poultice  of  flax- 
seed containing  one-sixteenth  part  of  mustard  and  covered  with  oiled  silk. 
The  cardiac  inflammations,  as  well  jis  rheumatism,  require  opiates  in 
sufficient  doses  to  procure  rest  and  sleep. 

Pleuritis,  which  Ave  have  stated  is  apt  to  be  suppurative,  demands  the 
same  treatment  as  the  idiopathic  disease  when  it  occurs  in  cachectic 
patienta. 


CHAPTER  in. 

ROTHELN. 

TriE  dli?ea.se  known  as  rothein  has  heretofore  been  rare  in  Ainorica, 
In  the  Ejistern  continent,  on  tiie  other  hand,  it  appeai-s  to  have  been 
known  for  many  years,  and  American  physicians  fi-e(|nently  designate 
it  German  or  French  measles.     Meagre  and  imperfect  descriptions  of 


266  ROTHELN. 

this  malady  have  appeared  in  some  of  the  British  journals,  and  cases 
quite  fully  detailed  have  been  published  by  British  physicians. 

llotheln  is  not  entirely  a  new  disease  in  this  country,  though  most 
American  physicians  never  saw  a  case  of  it  until  since  the  year  1870. 
Cases  occurring  in  and  about  Boston  were  described  by  Dr.  Honans,  Sr., 
in  1845,  and  at  a  later  date,  namely  in  18-38  and  1871,  B.  E.  Cotting 
and  Mr.  D.  Howard  saw  cases,  and  described  them  in  papers  read  before 
local  societies.  (See  Boston  Med.  and  Surg.  Journal,  March  15, 1873.) 
In  1874,  Dr.  Caleb  Green,  of  Homer,  Courtland  County,  New  York, 
an  accurate  and  intelligent  observer,  also  witnessed  an  epidemic. 

This  hitherto  rare  and  interesting  malady  occurred  in  New  York  City 
as  an  epidemic  in  1873  and  1874,  attaining  its  maximum  prevalence  in 
March  and  April  of  the  latter  year,  after  which  it  daclined,  occasional 
cases  occurring  throughout  May.  This,  so  far  as  I  can  learn,  was  the 
first  occurrence  of  rotheln  in  this  locality.  In  a  general  practice  of  more 
than  twentyyears,  extending  over  a  considerable  portion  of  this  city,  I 
had  previously  seen  nothing  like  it,  and  other  older  physicians,  having  a 
large  general  practice,  have  informed  me  that  they  consider  it  an  entirely 
new  disease  with  us.  Those  who  believe  that  they  have  occasionally 
observed  isolated  cases  of  it,  previously  to  the  epidemic,  probably  refer 
to  roseola. 

The  first  case  which  I  met  with  occurred  in  the  middle  of  December, 
1873,  in  West  Seventy-first  Street,  in  the  northern  suburbs  of  this  city. 
A  few  weeks  later  cases  were  so  numerous  in  the  more  thickly  populated 
section  of  New  York  as  to  attract  the  attention  of  many  physicians.  It 
was  evident  that  a  disease  had  appeared  with  which  we  were  not  familiar, 
and  as  the  eruption  occurred  in  points  and  small  circumscribed  patches, 
it  was  usually  designated  by  the  physicians,  in  want  of  a  more  accurate 
name,  epidemic  roseola,  or  was  spoken  of  as  a  spurious  measles.  Physi- 
cians who  were  familiar  with  foreign  medical  literature  saw  the  resem- 
blance between  these  cases  and  those  of  rikheln,  as  described  by  British 
and  continental  writers,  but  in  certain  at  least  of  the  foreign  cases  the 
duration  of  tlie  rash  was  said  to  be  seven  days  (Liveing,  London  Lancet, 
March  14,  1874,  and  3Iiid.  News  and  Library,  JNIay,  1874),  wliereas  in 
the  cases  in  New  York  it  commonly  disappeared  by  the  fourth  day. 
This  discrepancy,  however,  was  not  sufficient  to  invalidate  the  belief  in 
the  identity  of  the  New  York  disease  with  the  foreign  rotheln.  It  was 
readily  explained  by  the  difference  in  the  seasons  in  which  the  cases 
occurred,  for  Liveing  observed  his  cases  in  June  and  July,  and,  as  we 
will  see,  the  greater  the  external  heat,  the  longer  is  the  duration  of"  the 
eruption. 

Between  the  middle  of  December,  1873,  and  May  1,  1874,  I  had 
observed  and  treated  this  malady  in  eighteen  families.  Cases  occurred 
in  three  other  families  living  in  the  same  houses  with  some  of  those 
which  I  attended,  and,  as  they  were  fidly  and  clearly  described  to  me, 
60  that  there  could  be  no  doubt  as  to  tbeir  nature,  I  have  included  them 
in  my  statistics.  The  total  number  of  cases  in  these  twenty-one  families 
was  fortv-eight.  During  ]\Liy.  wben  the  epidemic  w;is  declining,  I  saw 
six  additional  cases,  occurrinir  singly,  making  a  total  of  fifty-four.  Their 
ages  are  given  in  the  following  table: 


PREMONITORY    STAGE.  267 

Age.  Caaea. 

From  eight  months  to  one  year      .......  2 

"      one  year  to  two  years  ........  4 

"      two  years  to  five  years  .         .         .         .         .         .         .16 

"      five  years  to  ten  years           .......  23 

"      ten  years  to  fifteen  j-ears       .......  3 

"      fifteen  years  to  thirt}'  j'ears           ......  6 

Total  number  of  cases  .  .....     54 

The  age  of  the  youngest  patient  was  eight  months,  and  that  of  tlie  oldest 
thirty  years.  Seventy-two  per  cent,  of  the  total  number  were  between 
the  ages  of  two  and  ten  years;  so  that  rotheln  is  preeminently  a  disease 
of  childhood.  Individuals  in  and  beyond  the  middle  period  of  life  seem 
to  have  nearly  an  immunity  from  it.  The  age  of  the  oldest  patient  of 
whom  I  was  informed  in  the  epidemic  of  1873  and  1874  was  about  forty 
years.  On  March  25,  1873,  during  my  attendance  in  the  New  York 
Foundling  Asylum,  rotheln  appeared  in  a  boy  of  four  years;  in  the 
following  month  about  thirty  more  cases  occurred  in  this  institution,  all 
children,  while  among  the  large  number  of  female  nurses  and  employes, 
who  were  chiefly  between  the  ages  of  twenty  and  thirty  years,  all  but 
three  escaped. 

From  1874  to  1880  rotheln  did  not  prevail  in  New  York,  unless  now 
and  then  an  isolated  or  sporadic  case,  the  nature  of  which  was  not  recog- 
nized, and  wdiich  was  supposed  to  be  roseola.  On  August  9,  1880,  two 
cases  appeared  in  diil'erent  Avards  of  the  New  York  Foundling  Asylum, 
when  it  was  remembered  that  two  wx'cks  previously  these  children  had 
been  exposed  to  a  patient  in  the  hospital  attached  to  the  institution, 
wlio  had  what  the  physician  in  attendance  supposed  at  the  time  to  be 
roseola. 

C'onmiencing  with  these  two  cases  an  epidemic  occurred  in  the  asylum, 
mild  in  type,  affecting  only  a  few  at  a  time,  but  extending  over  several 
montiis,  until  about  sixty  inmates,  chiefly  children,  were  attacked. 
Toward  the  close  of  1880  rotheln  began  to  appear  in  the  northern  part 
of  the  city,  in  which  the  asylum  is  located,  and  over  which  my  ])ractice 
extends.  Its  maximum  prevalence  was  attained  in  the  latter  part  of 
March  and  April,  1881,  when  it  particularly  attracted  the  attention  of 
plivsicians.  A  large  proportion  of  the  children  attending  certain  ])ublic 
and  private  schools  were  attacked.  It  occurred  in  seventeen  families  in 
my  practice.  The  ages  of  the  patients  in  these  families  are  given  in  the 
following  table: 

Age.  Cases. 

From  one  to  two  years  .........       3 

"      two  to  five  years  .........       8 

"       five  to  ten  years   .........     18 

"      te?i  to  fifteen  years        .         .         .  .         .         .         .         .11 

There  were  two  cases  over  fifteen  years,  aged  respectively  twent}'- 
two  and  forty-two  years      ........       2 

Total  number  of  cases  .......     42 

Premonitory  Stage. — Preinonitoi-y  symptoms  arc,  in  most  instances, 
absent,  or  so  mild  as  to  attract  but  little  attention.     It  not  infrequently 


2G8  ROT  II  EL  X. 

happened  in  the  Ne"\v  York  epidemics  that  the  parents  or  the  teachers 
in  the  schools  were  first  made  aware  of  the  illness  of  the  children  by 
observing  the  eruption.  In  some  instances  children  Avere  sent  from 
school,  not  because  they  felt  too  ill  to  remain,  but  on  account  of  the 
unusual  appearance  of  the  skin.  Sometimes,  however,  in  those  old 
enough  to  express  their  sensations,  a  premonitory  stage  of  some  hours, 
or  a  day,  or  even  of  longer  duration,  was  present;  consisting  of  such 
symptoms  as  usually  occur  when  one  has  taken  a  severe  cold,  as  lan- 
guor, pain  in  the  head,  trunk,  or  limbs.  The  resident  physician  of  the 
New  i'ork  Foundling  Asylum  was  so  ill  with  rotheln  that  he  was  con- 
fined to  his  bed  during  the  first  day  of  the  disease.  Now  and  then 
patients  experience  nausea  previously  to  the  eruption,  and  in  the  first 
and  second  days  of  the  eruptive  stage.  In  only  one  instance  did  I 
observe  grave  prodromic  symptoms.  A  boy,  aged  eight  years,  was  sud- 
denly seized  with  clonic  convulsions,  and  while  in  a  warm  bath  for  the 
relief  of  these,  the  rash  appeared  upon  those  parts  of  the  body  which 
were  immersed  in  water. 

Symptoms. —  Teriumentary  System,  {a)  TJie  Skin. — The  eruption 
commonly  commences  upon  the  forehead,  around  the  ears,  and  along  the 
neck,  as  in  measles.  Occasionally  it  may  appear  upon  the  back  or 
chest,  as  in  the  above-mentioned  case,  in  which  the  hot  water  accelerated 
its  appearance.  Commencing  above  the  efflorescence  travels  downward, 
appearing  after  some  hours  upon  the  lower  part  of  the  trunk  and  on  the 
logs,  resembling  in  this  respect  the  eruption  of  measles  and  scarlatina. 
It  occurs  upon  all  parts  of  the  integument,  except  the  scalp  and  palmar 
and  plantar  surfaces.  In  the  majority  of  the  cases  which  I  have  seen 
it  gradually  faded  away,  disappearing  by  the  fourth  day,  but  in  children 
who  were  kept  warm  in  bed,  or  in  warm  apartments,  it  remained  longer 
than  on  others.  In  many  instances  traces  of  the  rash  were  still  visible 
several  days  after  recovery  when  the  patients  were  heated  by  exercise 
or  excitement.  It  reappeared  at  times,  though  indistinctly,  on  a  girl 
of  thirteen  years,  for  three  weeks.  In  most  of  the  cases  in  the  New 
York  epidemics  the  eruption  commonly  occurred  in  points  and  circular 
spots,  somewhat  smaller  than  those  of  measles.  These  points  and  spots 
were  numerous  and  thickly  set,  so  that,  in  the  aggregate,  they  covered 
at  least  half  of  the  surface,  while  between  them  the  skin  presented  nearly 
or  quite  its  normal  appearance.  The  general  aspect  in  most  cases  was 
more  like  that  of  measles  than  that  of  scarlatina,  but  in  exceptional 
instances  the  skin  between  the  points  and  spots  had  a  redness  similar  to 
that  of  erythema,  and  tlie  resemblance  was  very  like  the  scarlatinous 
efflorescence.  Thus,  in  a  boy  of  three  years,  the  eruption  so  closely 
resembled  the  scarlatinous  over  the  trunk,  that  were  it  not  that  the 
temperature  was  constantly  below  100°,  and  all  febrile  movements  ceased 
within  three  or  four  days,  I  would  probal)ly  have  considered  the  malady 
a  mild  scarlatina.  In  certain  patients  the  eruption,  beginning  in  cir- 
cumscribed spots,  like  that  of  measles,  becomes  in  two  or  three  days 
confluent,  so  as  to  resemble  that  of  scarlatina,  while  over  other  parts  the 
spots  remain  discrete.  This  Avas  the  character  of  the  eruption  upon  the 
third  and  fourth  days  on  the  extremities  of  a  little  boy  in  the  Found- 


SYMPTOMS.  269 

ling  Asylum.  The  rash  is  attended  by  considerable  itching,  from  which, 
indeed,  many  patients  suffer  more  than  from  all  other  symptoms. 

The  eruption  disappears  on  pressure,  produces  a  slight  roughness  of 
the  surface,  as  ascertained  by  passing  the  fingers  gently  over  it,  and 
usually  flides  away  without  desquamation.  Exceptionally,  there  is  a 
sliglit  branny  exfoliation,  and  in  one  of  my  patients  this  was  as  consid- 
erable over  the  abdomen  as  in  cases  of  scarlatina. 

(Ji)  The  Mucous  jMcmhrane. — In  connection  with  the  cutaneous  erup- 
tion a  mild  inflammation  also  occurs  upon  the  mucous  membrane  cover- 
ing the  fauces,  buccal  cavity,  and  nostrils,  and  upon  reflections  of  this 
membrane  ov'er  the  eyes  and  eyelids,  2.^.,  upon  the  conjunctiva.  In 
certain  patients  this  inflammation  is  scarcely  appreciable,  but  in  the  ma- 
jority it  arrests  attention  at  once.  It  produces  a  suffused,  reddish,  or 
weak  appearance  of  the  eyes,  with  a  moderately  increased  lachrymation. 
On  everting  the  eyelids  the  palpebral  conjunctiva  is  seen  to  be  injected. 
In  certain  patients  a  moderate  puriform  secretion  collects  at  the  inner 
angle  of  the  eyelids.  In  occasional  cases  the  conpinctivitis  causes  oedi'ma 
of  the  lids,  usually  slight,  and  likely  to  be  overlooked  by  the  physician; 
but  in  three  instances  which  I  now  recall  to  mind,  the  mothers  of  the 
children  directed  my  attention  to  the  swollen  state  of  the  lids.  In  one 
of  these,  an  infant  of  twenty-three  months,  the  tumefaction  was  so  great, 
commencing  about  the  time  the  eruption  began  to  fade,  that  light  was 
totally  excluded  from  the  eyes,  and  it  was  impossible  to  ascertain  their 
condition.  The  skin  over  the  eyelids  retained  nearly  its  normal  ai)pear- 
ance,  and  a  puriform  secretion  appeared  between  the  lids.  In  three  or 
four  days  the  oedema  of  the  lids  and  the  hypeniemia  of  the  conjunctiva 
rapidly  declined.  The  coryza  is  in  most  cases  sufficient  to  cause  an 
unpleasant  sensation  in  the  nostrils  and  provoke  sneezing;  but  the  flow 
from  the  nostrils,  though  ])resent,  was  in  no  instance  under  my  oI>serva- 
tion  as  abundant  as  in  ordinary  cases  of  scarlatina,  or  even  of  measles. 
The  fauces  present  an  injected  appearance,  and  in  severe  cases  there  is 
moderate  swelling  of  the  tonsils.  The  same  catarrhal  hypernemia  is  also 
seen  in  spots  or  patches,  more  or  less  diffused,  upon  the  buccal  surfaces. 
Both  the  fiiucial  and  buccal  catarrii  are  less  in  degree,  however,  thiin  in 
cases  of  rubeola  and  scarlatina,  which  have  an  equal  intensity  of  cuta- 
neous enqjtion,  and  tliis  fact  has  aided  me  in  difi'eix'utial  diagnosis. 

The  Respiratory  Si/ntem. — In  both  the  epidemics  which  I  have  wit- 
nessed the  mucous  membrane  of  the  larynx,  trachea,  and  bronchial  tubes 
partici|)ated  only  slightly  in  the  inllammation  which  involved  tlie  n:is;il, 
buccal,  and  faiicial  surfaces.  IMaiiy  of  my  f)atients  had  no  cough,  but 
others  had  a  mild  cough  lasting  for  a  few  days,  but  with  normal  respira- 
tion. It  was  due  apparently  to  a  very  mild  catarrh  of  the  respiratory 
tract  at  the  time  when  the  nasal  and  conjunctival  surflices  were  the  most 
affected.  It  subsided  in  a  few  days  witliout  treatment.  In  no  case  do 
1  recollect  that  there  was  any  hoarseness. 

The  JfijicHtive  Si/sitem. — The  tongue  in  rotlieln  is  moist  and  of  )ior- 
mal  appearance,  or  covered  by  a  slight  fur.  'The  aj>]>etite  maybe  iui- 
paired,  but  is  not  wanting  in  uncomplicated  cases.  The  patients  some- 
times say  that  it  is  nearly  the  same  as  in  health,  the  thirst  is  sliglit.  and 
the  bowels  ai"e  regular. 


270  ROTHELN. 

Nausea  is  not  infrequent,  and  vomiting  was,  in  several  cases  in  my 
practice,  one  of  the  niitial  symptoms.  In  certain  patients  it  also  occurred 
on  the  first  or  second  day  of  the  eruption.  In  others  there  was  no  nausea, 
so  far  as  I  could  learn,  either  immediately  before  or  during  the  preva- 
lence of  the  disease.  This  symptom  is  less  frequent  in  rotheln  than  in 
scarlet  fever,  but  is  a?  common  ;ij)parently  as  in  measles.  I  have  never 
found  albumen  in  the  urine,  though  I  have  examined  that  passed  by 
several  patients.  This  secretion  did  not^  appear  to  be  abnormal  except 
as  it  contained  urates,  so  common  in  febrile  states. 

Tlie  Pulse  and  Temperature. — The  largest  number  of  accurate  daily 
observations  relating  to  the  temperature  was,  I  think,  that  of  Dr.  Reid 
in  the  Now  York  Foundling  Asylum  during  the  month  of  March,  1874. 
lie  has  kindly  furnished  me  with  his  statistics  relating  to  this  symptom 
as  follows:  "The  number  of  closely  observed  cases  in  which  the  tem- 
perature was  taken  was  twenty-four.  In  seventeen  of  the  cases  the 
temperature  ranged  from  97°  to  99°,  in  six  it  reached  100°,  100J°, 
and  10!)|°;  in  one  it  reached  103^°  on  the  second  day  of  the  eruption, 
but  remained  so  elevated  only  one  day."  In  certain  patients  Doctor 
Reid  observed  what  he  designates,  "a  tendency  to  the  development  of  an 
ephemeral  fever."  These  observations  correspond  closely  with  those 
made  by  myself  during  the  same  epidemic.  Thus,  in  16  cases  I  found 
the  axillary  temperature  taken  each  day  to  be  constantly  between  98° 
and  10l»°,  with  a  pulse  under  110,  except  in  one  case,  in  which  it  num- 
bered 124.  In  certain  other  patients  a  more  decided  febi-ile  movement, 
lasting  from  one  to  two  or  three  days,  occurred,  usually  in  the  commence- 
ment of  the  malady.  Thus,  a  girl  aged  three  and  a  half  years  had  a 
temperature  of  101  J°  and  a  pulse  of  128.  In  another  instance  the  pulse 
was  124  and  the  temperature  102°.  In  another,  a  girl  of  three  and  a 
half  years,  there  was  active  febrile  movement  occurring  without  apparent 
cause  on  Saturday  night,  but  abating  on  the  following  day.  She  seemed 
well  until  the  following  Tuesday,  when  the  febrile  movement  returned 
and  the  eruption  appeared.  On  Thursday  the  temperature  from  102° 
to  103°  fell  to  99J°,  and  within  a  day  or  two  she  was  convalescent.  In 
two  other  patients  from  two  to  four  days  after  the  disappearance  of  the 
eruption  an  accession  of  fever  occurred,  lasting  about  one  day,  and 
attended  l)y  pain  and  distress  in  the  epigastric  region,  but  without  vomit- 
ing or  diarrhoea.  In  one  of  these  the  temperature  was  103|°,  the  pulse 
130  per  minute.  In  the  otlier  case  the  temperature  and  pulse  did  not 
seem  to  be  under  these  figures,  but  were  not  accurately  ascertained. 
Occasionally  the  febrile  movement  is  due  more  to  complications  than  to 
the  primary  disease.  Thus,  in  two  of  my  patients  the  febrile  movement 
was  mainly  attributable  to  diphtheritic  inflammation  Avhich  had  attacked 
the  fauces.  But  while  the  fever  in  rotheln  is  ordinarily  of  short  dura- 
tion, in  certain  patients  temporary  exacerbations  may  occur  in  which  the 
temperature  is  as  high  as  in  scarlet  fever  or  measles. 

Complications — Prognosis. — The  only  complication  which  occurred 
in  cases  in  my  practice  has  already  been  alluded  to,  namely,  diphtheria, 
which,  Avhen  prevalent,  is  apt  to  attack  surfaces  already  inflamed.  In 
the  Foundling  Asylum  varicella  complicated  one  case  and  pneumonia 
another.     In  a  third  pneumonia  occurred  about  three  days  after  the 


NATURE.  271 

disappearance  of  the  eruption.  The  prognosis  in  uncomplicated  cases 
is  always  very  lavorable,  and  there  is  no  liability  to  sequelne  more  than 
in  mild  catarrhal  inflammations  of  a  non-specific  character.  The  duration 
of  rotheln  is  short,  not  ordinarily  extending  beyond  three  to  five  days. 

Nature — Incubative  Period — Contagiousness. — Is  rotheln  a  dis- 
tinct malady  or  one  Avith  Avhich  Ave  are  familiar,  but  the  form  and  char- 
acter of  Avliich  are  modified  by  unusual  meteorological  conditions?  Is 
it  roseola  assuming  at  certain  periods  an  epidemic  character,  and  a^^ear- 
ing  to  be  contagious  ?  Or  is  it  at  all  times  infectious,  possessing  a  specific 
principle,  and,  like  other  infectious  diseases,  self-propagating?  Should 
it  in  nosological  classification  be  placed  among  the  non-contagious  and 
local,  or  among  the  constitutional  and  infectious  maladies?  Let  us  con- 
sider the  facts  observed  in' the  NeAV  York  epidemics. 

The  first  cases  of  rotheln  in  this  city  were  often  designated  roseola  by 
the  physicians  called  to  treat  them,  since  they  seemed  to  resemble  more 
closely  this  disease  than  any  other  Avith  Avhich  they  Avere  familiar.  But 
rotheln  differs  Avidely  from  the  peculiar  form  of  dermatitis  knoAvn  as 
roseola.  The  successive  occurrence  of  the  eruption  over  the  upper  and 
then  the  lower  parts  of  the  body,  but  covering  the  Avhole  surface,  and 
the  definite  duration  of  three  to  five  days,  are  points  of  difference.  More- 
over, roseola  Avould  not,  Avithout  so  great  change  in  its  character  as  to 
become  virtually  a  distinct  disease,  occur  in  the  cool  months  without  any 
appreciable  dietetic  cause,  as  an  epidemic  over  a  certain  area  and  for  a 
limited  time,  affecting  Avhole  households  and  sparing  other  households, 
as  well  as  individuals  of  a  certain  age.  We,  therefore,  consider  it  dis- 
tinct from  roseola. 

Most  of  the  cases  in  the  Ncav  Yoi'k  epidemics  bore  considerable  resem- 
blance to  measles,  both  as  regards  the  appearance  and  duration  of  the 
eruption  and  the  catarrh  of  the  mucous  surflices.  Parents  often  diag- 
nosticated measles  before  the  arrival  of  the  physician,  and  the  physician 
himself,  at  first  glance,  sometimes  made  the  same  diagnosis.  But  in 
rotheln  the  shortness  and  mildness  of  the  stage  of  iuA'asion,  the  absence 
of  cough  or  the  presence  of  one  trivial  and  scarcely  noticed,  appetite 
good  or  but  slightly  impaired — in  fine,  symptoms  that  are  transient  or 
slight,  afford  a  striking  contrast  to  the  graver  symptoms  of  measles.  But 
the  decisive  proof  that  rotheln  is  not  a  modified  measles  is  found  in  the 
fact  that  one  does  not  prevent  the  other.  Of  the  forty-eight  cases  ob- 
served by  myself,  prior  to  May  1st,  in  the  epidemic  of  1874,  nineteen  at 
least  had  had  measles,  and  one  Avho  had  rotheln  took  measles  subscfjuently. 
I  have  already  stated  that  in  the  New  York  Foundling  Asylum  rcitiieln 
in  1S7'S  and  1H74  closely  folloAVcd  an  epidemic  of  measles.  A  consider- 
able number  of  the  children  attacked  by  the  former  disease  had  recently 
recovered  from  the  latter.  During  the  epidemic  of  1880  and  1881  tiie 
same  fact  Avas  observed,  namely  that  a  previous  attack  of  measles  as  Avell 
as  scarlet  fever  afforded  no  protection  from  rotheln.  Dr.  Chadbournc, 
the  resident  physician,  Avrites  of  the  cases  in  the  Foundling  Asylum  in 
1880  and  1881':  "Eight  children  had  rotheln  who  had  had  hotli  scarlet 
fever  and  measles  Avithin  six  months  under  my  obserwation,  Avhile  certain 
others  had  had  these  diseases  at  some  previous  time."  Of  the  cases 
observed  by  myself  in  family  practice  in  the  same  epidemic,  it  is  stated 


272  ROTHELN. 

in  my  notes  that  ten  had  had  measles.  These  statistics  are  sufficient  to 
show  that  rotheln  is  a  distinct  disease  from  measles,  however  close  the 
kinship. 

That  rotheln  is  not  a  form  of  scarlet  fever  is  evident  from  the  fact 
that  as  regards  at  least  the  New  York  epidemics  the  rash  was  in 
most  instances  quite  distinct  from  the  scarlatinous  efflorescence,  occur- 
ring, as  we  have  said,  in  small  more  or  less  circular  points  and  patches. 
Moreover,  as  we  have  remarked  above,  there  is  in  rothehi  a  slight 
febrile  movement  and  general  mildness  of  symptoms,  which  contrast 
with  the  high  fever  and  other  pronounced  symptoms  of  scarlatina,  or  if 
there  be  considerable  febrile  movement  its  duration  is  brief  But  the 
conclusive  proof  of  an  essential  difference  between  these  two  diseases  is 
found  in  the  fact  already  stated  in  reference  to  measles,  that  the  attack 
of  the  one  malady  does  not  prevent  the  occurrence  of  the  other.  There 
are,  it  is  true,  cases  in  which  it  is  difficult  at  fii'st  to  make  the  differ- 
ential diagnosis  between  rotheln  and  mild  measles  or  mild  scarlet  fever, 
but  when  the  course  of  the  malady  has  been  closely  observed  for  three 
or  four  days,  it  will  rarely  happen,  I  think,  that  we  will  be  unable  to 
make  out  its  character. 

Those  cases  of  an  epidemic  which  arise  when  the  causes  or  conditions 
from  which  it  is  developed  are  most  strongly  operative  and  which  at  this 
time  are  apt  to  be  typical,  obviously  afford  the  best  data  for  studying  its 
nature.  Such  were  the  forty-eight  cases  which  I  saw  in  the  epidemic 
of  1873  and  1874,  and  the  "forty-two  in  that  of  1880  and  1881.  As 
regards  the  former  epidemic,  in  thirteen  of  the  tw'enty-one  families 
embraced  in  my  statistics,  the  first  cases  were  children.  Avho  up  to  the 
time  of  the  seizure  were  attending  public  and  private  schools,  and  in 
certain  instances  those  who  were  nearly  simultaneously  attacked,  living 
perhaps  in  streets  widely  separated,  were  attending  the  same  school. 
During  the  epidemics  of  1880  and  1881,  the  first  patients  in  thirteen 
of  the  eighteen  families  in  which  rotheln  occurred  in  my  practice  were 
school  children  between  the  ages  of  six  and  twelve  years,  and  in  most, 
if  not  all,  the  different  schools  which  they  attended,  rotheln  was  at  the 
time  prevailing  as  an  epidemic,  as  I  ascertained  on  inquiry.  It,  there- 
fore, seemed  probable  that  these  children  whom  I  attended  had  con- 
tracted it  from  others  in  the  schools. 

In  both  the  New  York  epidemics  during  the  time  that  riuheln  was  at 
its  maximum  prevalence,  in  most  of  the  fiimilies  containing  two  or  more 
children  the  cases  were  multiple,  not  occurring  simultaneously,  but  in 
succession,  as  if  the  malady  was  contracted  from  those  first  affected. 
This  is  what  we  daily  witness  in  the  spread  of  exanthcmatic  fevers. 
Thus  in  Mr.  E.'s  family,  a  girl  attending  one  of  the  public  schools  took 
rotheln  in  the  middle  of  December,  1873  ;  the  two  remaining  children 
sickened  with  it  one  week  and  two  weeks  later.  A  niece  visiting  in  the 
family  at  the  time  when  the  first  child  was  sick,  but  returning  home  to 
another  street,  also  had  the  eruption  on  December  27th.  Alice  R., 
aged  ten  years,  a  frequent  visitor  at  Mrs.  E.'s,  living  in  the  same  street, 
and  several  times  exposed  to  his  children  during  their  illness,  also  took 
rotheln  about  January  4th.  West  Seventy-first  Street,  where  these 
cases  occurred,  is  thinly  settled  and  suburban,  and  I  could  learn  of  no 
other  cases  in  the  vicinity.     A  child  of  Mr.  P.,  aged  five  and  a  half 


NATURE.  273 

years,  had  been  in  the  habit  of  playing  with  two  children  two  doors 
away  who  became  affected  with  rotheln  in  the  beginning  of  April. 
ltS81.  On  April  14th  he  was  supposed  to  have  a  mild  coryza  from 
taking  cold,  as  he  sneezed  often,  but  in  a  few  hours  the  efflorescence 
appeared.  Four  days  subsequently  on  the  18th,  an  infant  was  affected 
in  the  same  way,  and  thirteen  days  later  another  child  in  the  family, 
aged  twelve  years.  In  a  similar  manner  rotheln  occurred  in  the  families 
of  two  brothers  living  in  adjoining  houses  in  West  Fifty-first  Street, 
The  first  patient  Avas  a  boy  of  twelve  years.  It  appeared  successively 
in  the  children  of  these  two  families  until  ten  had  been  affected.  In  a 
family  in  West  Forty-sixth  Street,  the  first  case  Avas  a  boy  attending  a 
school  in  which  rotheln  was  prevalent.  Within  twenty  days,  namely, 
between  ^Nlarch  31st  and  April  20th,  four  other  children  were  attacked 
in  succession. 

These  facts  and  cases  seem  to  demonstrate  the  contagiousness  of 
rotheln.  at  least  durino;  the  time  in  which  the  conditions  are  most  favor- 
able  for  its  development,  or  during  the  time  in  Avhich  the  epidemic 
influence  is  most  pronounceil.  In  the  declinini^  period  of  both  the  New 
York  epidemics,  the  cases  which  I  ol)served  occurred  for  the  most  part 
singly,  although  there  was  no  attempt  to  isolate  the  patients,  so  that  the 
contagiousness  of  the  disease,  if  present,  must  have  been  very  slight. 

Rotheln  is,  in  my  opinion,  an  exanthematic  fever  feebly  contagious. 
It  resembles  varicelhi  in  general  mildness  of  symptoms,  in  the  absence 
of  dangerous  complications  or  se(]uel«,  and  in  the  uniformly  favorable 
prognosis,  while  its  SAmiptoms  show  a  resemblance  to  measles  and  scarlet 
fever. 

If  the  above  view  be  correct,  rotheln  must  possess  an  incubative 
period  which,  in  the  cases  observed  in  both  epidemics,  apparently  varied 
between  seven,  or  perhaps  less  than  seven,  and  twenty-one  days.  Its 
incubation,  therefore,  resembles  that  of  scarlet  fever,  which,  as  is  well 
knoAvn,  varies  in  different  patients.  In  the  cases  wiiich  came  under  my 
notice,  the  incubative  period,  when  it  could  be  accurately  ascertained, 
was  more  frecjuently  about  two  weeks,  than  a  longer  or  shorter  period. 
The  resident  physician  of  the  New  York  Foundling  Asylum,  when  the 
epidemic  was  ])revailing  in  that  institution,  returned  to  his  home  in  the 
State  of  Maine  to  a  locality  where  rotlieln  was  unknown.  Fourteen 
days  from  the  date  of  his  departure  he  was  himself  affected  with  the 
disease  in  its  typical  form.  No  other  case  occurred  at  his  home,  where 
jirobably  the  atmospheric  conditions  were  unfavorable.  Minnie  B., 
attending  a  school  in  which  there  were  many  cases,  had  the  rash  on 
April  r)th.  On  the  23(1  of  the  same  month,  eighteen  days  afterward, 
it  ap|)eared  upon  the  servant  who  was  freipiently  in  Minnie's  room. 
Elizabeth  C,  attending  a  school  in  which  riitheln  was  ])revailing,  had 
the  eruption  on  April  ITtli.  It  commenced  upon  her  sister  thirteen 
days,  and  upon  her  mother  fourteen  days  subsc(piently. 

Oth(!r  cases  might  be  cited  of  an  apjiarently  shorter  as  well  as  longer 
incubative  period.  The  following  note  from  Dr.  (^hiidbourne,  of  tlie 
New  York  Fuumlling  Asylum,  bearing  upon  this  subject,  is  interesting: 
"I  am  led  to  believe  from  my  observations  that  the  period  of  incubation 

18 


27-i  VARIOLA. 

was,  in  tlic  majority  of  the  cases,  from  twelve  to  fifteen  days.  The  dis- 
ease has  been  very  feebly  contagious.  In  some  cases  one  child  would 
have  rotheln  while  the  other,  nursed  by  the  same  woman,  would  escape. 
In  two  instances  women  had  the  disease,  and  though  each  suckled  two 
infants  the  latter  escaped." 

Rotheln  requires  no  treatment. 


CHAPTER     lY. 

VARIOLA— VAEIOLOID. 

Variola,  or  smallpox,  is  a  specific  febrile  affection,  accompanied  by 
a  vesiculo-pustular  eruption  upon  the  skin.  Since  the  discovery  of  the 
protective  power  of  vaccination  it  has  been  shorn  of  much  of  its  terror, 
but  it  is  still  the  most  loathsome  and  most  dreaded  of  all  the  fevers. 
Two  forms  of  this  disease  are  recognized,  depending  on  the  fact  whether 
there  have  been  previous  vaccination.  If  the  patient  have  been  vacci- 
nated at  some  period  in  his  life,  the  disease,  which  is  rendered  milder 
in  consequence,  is  designated  varioloid.  If  there  have  been  no  vaccina- 
tion, it  is  called  variola  or  smallpox.  Both  forms  are  identical  in  nature, 
the  one  communicating  the  other ;  they  dift'er  only  in  gravity. 

Smallpox  presents  four  stages :  the  initial,  or  that  of  invasion  ;  the 
eruptive;  that  of  desiccation  ;  and,  lastly,  that  of  desquamation.  It  is 
termed  discrete  when  the  pustules  remain  separated  from  each  other ; 
confluent  when  they  unite.  This  division  is  made  according  to  the 
character  of  the  eruption  upon  the  face  and  IkukiS.  There  are  parts  of 
the  surface,  as  the  abdomen,  where  the  pustules  are  always  discrete, 
even  in  the  confluent  form. 

Incubative  Period. — During  the  last  half  of  the  last  century  inoc- 
ulation with  variolous  matter  was  extensively  practised  in  Great  Britain 
and  on  the  Continent,  as  it  was  found  that  smallpox  thus  communicated 
was  milder  than  when  received  by  infection.  This  operation  enabled 
physicians  to  determine  the  period  of  incubation,  which  was  found  to  be 
from  eiglit  to  eleven  days.  When  variola  is  communicated  through  the 
air,  the  incubative  period  is  somewhat  longer,  to  wit,  from  twelve  to 
fourteen  days. 

Stage  of  Invasion. — Smallpox  begins  abruptly  with  chilliness.  In 
children  of  an  advanced  age  there  is  often,  as  in  the  adult,  a  distinct 
chill.  This  is  followed  by  fever  and  such  symptoms  as  usually  accom- 
pany febrile  movement,  namely,  lassitude,  anorexia,  and  thirst.  In 
addition  certain  symptoms  arise  which,  though  not  peculiar  to  smallpox, 
are  so  marked  in  the  commencement  of  this  disease,  that  they  possess 
considerable  diagnostic  value.  These  symptoms,  which  pertain  to  the 
nervous  system  and  occur  in  the  initial  stage  of  varioloid  as  well  as 


STAGES    OF    ERUPTION.  275 

variola,  are  severe  frontal  headache,  pain  in  the  small  of  the  back,  and 
great  drowsiness,  sometimes  ■with  delirium,  in  many  children  convul- 
sions occur,  preceded  and  followed  by  a  degree  of  stupor  whicli  is 
almost  as  profound  as  coma.  Trousseau  sufjwsts  the  name  rachialfjia 
for  the  pain  in  the  back,  as  he  believes  that  it  is  located  in  or  around 
the  spinal  cord.  This  belief  is  based  on  the  fiict  which  he,  as  well  as 
other  observ^ers,  has  noticed,  that  there  is  sometimes  in  connection  with 
this  symptom  an  incomplete  paraplegia,  indicated  by  numbness  of  the 
legs,  or  even  inability  to  use  them,  and  sometimes  more  or  less  paralysis 
of  the  bladder.  These  paraplegic  symptoms  pass  off  in  a  few  days. 
Vomiting  is  also  a  common  symptom  in  this  stage,  and  one  also  of 
diagnostic  value.  It  occurs  at  short  intervals  for  twenty-four  to  thirty- 
six  hours.  The  same  symptom  is  common  in  scarlet  fever,  and  not  in- 
frequent in  measles,  but  in  both  these  maladies  irritability  of  stomach 
is  much  less  persistent  than  in  smallpox  ;  vomiting  does  not  occur  in 
normal  rubeolous  and  scarlatinous  cases  more  than  once  or  twice. 

The  tongue  is  covered  with  a  moist  fur.  If,  the  disease  is  to  be  dis- 
crete, constipation  is  commonly  present  in  the  stage  of  invasion  ;  if  con- 
fluent, diarrhoea  is  a  common  symptom,  continuing  till  the  fourth  or 
fifth  day,  or  even  longer.  Roseola  or  erythema  sometimes  occurs  in 
this  stage,  and  this  may  lead  to  error  of  diagnosis,  the  disease  being 
mistaken  for  one  of  these  cutaneous  affections,  or  even  for  scarlet  fever. 
The  symptoms  in  the  stage  of  invasion  are  usually  more  violent  in  con- 
fluent than  in  discrete  variola,  but  there  are  exceptions. 

Stage  of  Eruption. — The  eruption  commences  about  the  third  day, 
earlier  in  some  cases,  later  in  otliers.  The  average  duration,  therefore, 
of  the  first  stage  is  somewhat  shorter  than  in  measles,  but  considerably 
longer  than  in  scarlet  fever.  Sydenham  has  stated,  and  observations 
show  the  truth  of  the  remark,  that  the  shorter  the  first  stage,  the  more 
severe  the  disease  will  prove  to  be ;  and,  conversely,  the  longer  the 
period,  the  milder  will  be  its  form.  Therefore,  if  the  eruption  begin  on 
the  second  day,  it  Avill,  as  a  rule,  be  confluent ;  if  not  till  the  fifth  or 
sixth  day,  it  will  be  scanty  and  the  disease  light. 

Tlie  eruption  commences  in  minute  red  spots,  somewhat  like  those  of 
lichen,  whicii  gradually  enlarge.  It  is  first  observed  around  the  lips  and 
upon  the  neck,  then  upon  the  face,  scalp,  upper  part  of  chest,  arms,  and 
finally  upon  the  lower  part  of  the  chest,  the  abdomen,  and  legs.  It  is 
sometimes,  es})('cially  in  young  children,  first  observed  in  the  folds  of 
the  skin,  as  about  tlie  genitals  or  in  the  groin.  If  the  cuticle  be  irritated, 
as  by  a  sinapism,  tlie  eruption  often  appears  first  u[)on  tiiis  part  of  the 
surface  and  in  greater  abundance  than  elsewhere.  Commencing  in  a 
minute  reddish  point,  as  stated  above,  it  rapidly  enlarges,  and  soon  its 
central  part  begins  to  be  indurated  and  raised.  It  feels  round  and  bard 
to  the  finger,  is  tender,  and  its  diameter  does  not  ordinarily  exceed  two 
lines.  This  is  the  pa])idar  stage.  Tlie  papuhc  increase  and  become  more 
elevated,  and  in  twenty-four  to  forty-eight  hours  from  the  commence- 
ment of  the  eruptive  stage  they  become  vesicular.  On  the  fifth  day  of 
the  eruption,  or  eighth  of  the  disease,  the  vesicle  has  attained  its  full  size. 
Its  diameter  is  then  about  one-fourth  of  an  inch,  and  its  elevation  is  two 
or  three  lines.     Its  base  is  circular  and  indurated,  and  it  is  surrounded 


276  VARIOLA, 

by  a  narrow  zone  of  inflammation,  indicated  by  redness  and  tenderness 
of  the  skin.  The  pock  commonly,  as  it  passes  from  the  papuhir  to  the 
vesicuhir  stage,  loses  its  acuminate  form,  and  becomes  depressed  in  the 
centre,  but  in  most  cases,  mixed  with  the  umbilicated  vesicles,  are  some 
which  remain  acuminate. 

In  proportion  as  the  eruption  becomes  developed  in  discrete  variola 
and  in  varioloid,  the  symptoms  which  accompanied  the  stage  of  invasion 
abate;  the  fever,  headache,  pain  in  tlie  back,  and  thirst  cease,  and  the 
appetite  returns.  In  the  confluent  form,  the  febrile  action  continues  with 
little  abatement. 

Simultaneously  with  the  eruption  upon  the  skin,  an  eruption  also  occurs 
upon  the  buccal  and  faucial  surftices,  and  often  upon  that  of  the  air-pas- 
sawes.  It  occurs  sometimes,  also,  upon  the  conjunctiva,  producing  dan- 
gerous ophthalmia,  and  even  ulceration,  with  loss  of  sight,  and  upon  the 
mucous  surface  of  the  genital  organs.  Tlie  form  which  it  presents  upon 
mucous  surfaces  is  somewhat  different  from  that  upon  the  skin.  There 
is  at  first  a  deposit  of  fibrin,  producing  a  small,  round,  grayish  spot  at 
the  point  of  eruption — firm,  slightly  elevated,  and  covered,  ifnotbythe 
entire  mucous  membrane,  at  least  by  its  epithelial  layer.  Ulceration 
soon  occurs,  as  in  ulcerous  stomatitis,  and,  if  the  patient  live,  the  repara- 
tive process  succeeds,  as  in  simple  ulcers.  The  eruption  upon  mucous 
surfaces  increases  considerably  the  suffering  of  the  patient,  in  conse- 
quence of  the  tenderness  of  the  ulcers;  and  if  its  seat  be  the  surface  of 
the  larynx  or  trachea,  it  may  be  the  immediate  cause  of  death,  especially 
in  .young  children,  by  obstructing  respiration. 

Tlie  cutaneous  eruption  has  been  traced  to  the  vesicular  stage.  On 
or  about  the  fifth  day  of  the  eruptive  period,  or  eighth  of  smallpox,  the 
vesicles  gradually  change  their  character,  their  contents  becoming  thicker 
and  turbid.  At  the  same  time  they  increase  still  more  in  size,  and  the 
central  depression  disappears.  This  is  designated  the  stage  of  matura- 
tion, or  of  su]ipuration,  though  it  is  known  that  the  turbidity  is  due 
chiefly  to  another  substance  than  pus.  The  pock  having  undergone  these 
changes,  is  termed  the  pustule. 

In  disci-ete  variola,  and  in  varioloid,  the  fever  returns  during  the  pus- 
tular stage;  or,  if  the  form  of  the  disease  be  confluent,  and  the  fever  have 
continued,  it  now  becomes  more  intense.  The  return  of  fever,  or  its  in- 
crease, is  denoted  by  increased  fi-equency  of  pulse,  elevation  of  tempera- 
ture, dryness  of  skin,  anorexia,  and  thirst.  A  tendency  to  constipation 
remains  throughout  in  varioloid  and  discrete  variola;  in  the  confluent 
form  diarrhoea  more  frequently  occurs,  which,  if  it  continue,  is  an  un- 
favorable prognostic  sign. 

Other  changes  occur.  The  pustules  increase  somewhat  in  size,  and 
become  more  globular.  Some  of  them,  when  most  distended,  break 
through  friction  of  the  clothes,  or  scratching  of  the  child,  and  their 
contents  escaping,  add  to  the  loathsomeness  of  the  disease.  There  is 
in  the  pustular  stage  more  or  less  redness  of  the  surface  between  the 
eruptions,  and,  except  in  the  mildest  cases,  tumefiiction  from  sub- 
cutaneous infiltration  occurs.  In  the  confluent  form,  at  this  period,  the 
features  are  often  so  swollen  that  the  friends  would  not  recognize  the 
patient.      The  eyelids  may  be  so  ocdematous  that  the  eyes  are  for  a 


STAGE    OF    DESICCATION.  277 

time  concealed  from  view.  This  oedema  of  the  siu'fice  is  not  altogether 
absent  in  the  vesicular  stage,  but  it  increases  during  the  time  of  matura- 
tion, after  which  it  subsides. 

Stage  of  Desiccation. — This  immediately  succeeds  the  full  develop- 
ment of  the  pustules.  The  liquid  portion  of  the  contents  of  the  pustules 
which  are  broken,  evaporates,  leaving  a  crust.  If  there  be  no  rupture, 
the  liquid  is  absorbed  and  a  scab  results,  which,  though  smaller,  preserves 
in  a  measure  the  form  of  the  pustule.  While  the  pustule  desiccates,  the 
surrounding  inflammation  rapidly  abates.  The  crusts  occur  first  upon 
the  face,  and  on  other  parts  in  the  order  in  which  the  eruption  appeared. 
The  odor  from  the  patient,  at  this  time,  is  peculiar.  In  the  confluent 
form,  especially,  it  is  very  offensive,  and  can  be  noticed  at  a  distance 
from  the  bedside.  Rilliet  and  Barthez  call  it  nauseous  and  fetid.  As 
desiccation  progresses,  the  symptoms,  local  and  general,  abate.  The 
pulse  and  temperature,  if  the  case  be  fiivorable,  return  to  their  normal 
standard.  The  cough,  hoarseness,  and  thirst  disappear,  while  the  appe- 
tite returns ;  the  sleep  is  more  tranquil,  and  tile  functions,  generally, 
are  more  regularly  performed. 

The  last  stage  is  tliat  of  desquamation ;  it  commences  between  the 
eleventh  and  sixteenth  days.  The  scabs,  which  present  a  dark  or  brown- 
ish appearance,  are  successively  detached.  This  period  lasts  several 
days ;  sometimes  two  or  three  weeks  even  elapse  before  all  the  crusts 
separate.  In  the  mean  time  the  patient  gradually  recovers  his  health  and 
formL-r  strength.  After  the  fall  of  the  crust,  the  cicatrix  underneath 
presents  a  reddish  apj)earance.  The  color  gradually  fides,  and  there 
remains  an  irregular  dejnx'ssion,  or  pit,  of  a  lighter  color  than  the  sur- 
rounding surface;  and  if  there  have  been  a  full  development  of  the 
eruption,  disfiguring  the  patient  for  life. 

Such  is  the  clinical  history  of  variola,  when  it  is  favorable,  and  its 
course  is  regular.  The  disease  is  sometimes  irregular.  In  rare  instances 
the  eruption  occurs  almost  at  the  commencement  of  the  attack.  The 
f  jrm  is  then  very  apt  to  be  confluent.  There  are  irregularities,  also,  in 
consequence  of  diarrhoea,  hemorrhages  or  other  complications.  I  have 
known  the  eruption  appear  first  on  the  limbs,  and  last  on  the  trunk  and 
face,  and  the  ap[)earancc  of  the  eruption  is  not  always  the  same.  In 
the  anjiemic  and  feeble  child  it  often  presents  a  pale  color,  with  some 
induration  at  its  base,  but  without  the  red  areola  around  it,  or  witli  this 
quite  indistinct.  In  rare  instances  the  vesicles  have  a  reddish  color, 
their  contents  being  tin";ed  with  blood.  This  form  of  variola  is  desig- 
nate<l  hemorrhagic.  It  indicates  a  profoundly  altered  state  of  the 
blood.  The  eruption  in  this  form  is  of  small  size,  and  if  the  pock  is 
broken,  blood  oozes  from  it. 

I  have  met  one,  perhaps  two  cases  of  malignant  hemorrhagic  small- 
pox, as  described  by  Ilcbra,  among  the  rare  forms  of  this  malady.  Tlie 
second  case  died  so  soon  that  we  were  undecided  whether  he  had  small- 
pox or  scarlatina.  A  man  aged  3(1  years,  previously  healthy,  became 
suddenly  and  severely  sick,  in  June,  IHMl,  with  fever,  intense  headache 
and  backache,  great  depression  of  the  vital  powers,  sUH'j)lessiiess,  and  a 
sensation  of  sinking  or  depression  in  the  e|)igastriiini.  He  had  a 
marked  foreboding  of  coming  evil,  and  begged  almost  constantly  for 


278  VARIOLA. 

relief.  Within  forty-eiglit  hours  a  heavy  and  continuous  dusky  scarla- 
tiniform  eruption  covered  the  whole  surface,  except  below  the  knees^ 
disappearing  on  pressure ;  fauces  at  first  but  moderately  injected.  On 
the  following  day,  the  third  of  his  sickness,  with  a  temperature  of 
104.5°,  the  efflorescence  became  a  dark  red,  numerous  small  extravasa- 
tions of  blood  had  occurred  under  the  skin,  the  urine  contained  blood, 
and  finally  seemed  to  consist  almost  entirely  of  dark  blood ;  a  large 
effusion  of  blood  under  the  entire  conjunctiva  of  either  eye  prevented 
closure  of  the  eyelids,  and  probably  hemorrhages  had  occurred  within 
the  eyes,  as  the  sight  was  neai'ly  lost.  Death  occurred  on  tlie  following 
day.  In  Hebra's  article  on  smallpox  is  the  description  of  precisely 
such  cases,  but  the  death  of  my  patient  was  too  early  for  exact  diagnosis. 

Varioloid. — The  course  of  varioloid  is  similar  to  that  of  variola, 
but  it  is  somewhat  shorter.  It  commences  with  rigors,  followed  by 
fever,  headache,  pain  in  the  back,  vomiting,  drowsiness  and  sometimes 
delirium,  or  even  convulsions.  The  symptoms  in  the  stage  of  invasion 
are,  indeed,  the  same  in  character,  and  often  nearly  as  severe  as  in 
variola.  With  the  initial  symptoms,  there  is  also  sometimes  a  scarlatini- 
form  eruption,  so  that  the  disease  may  at  first  be  mistaken  for  scarlatina. 
On  the  third  or  fourth  day  the  variolous  eruption  commences.  The 
number  of  pocks  is  commonly  few,  often  not  more  than  twelve  to  twenty. 
In  the  mildest  form  of  varioloid,  if  the  physician  be  not  summoned  in 
the  stage  of  invasion,  he  is  not  apt  to  be  called  at  all,  so  that  the  patient 
may  pass  through  the  disease  in  ignorance  of  its  nature.  The  true 
character  of  the  malady  is  not  ascertained  till  others  are  affected,  either 
with  variola  or  varioloid. 

The  eruption  pursues  a  more  rapid  course  in  varioloid  than  in  the  un- 
modified disease.  By  the  fifth  or  sixth  day  the  pustules  are  fully  devel- 
oped, though  often  smaller  and  less  likely  to  be  ruptured  than  in  variola. 
Often,  in  varioloid,  the  eruption  aborts.  It  remains  papular  two  or 
three  days,  and  then  declines,  or  it  may  reach  the  vesicular  stage,  and 
decline  without  pustulation. 

The  constitutional  symptoms  in  varioloid  abate  with  the  commence- 
ment of  the  eruptive  stage.     The  secondary  fever  is  slight  or  absent. 

Such  is  the  usual  mild  course  of  varioloid,  but  not  always.  If  sev- 
eral years  have  elapsed  since  the  vaccination,  its  protective  power  is 
greatly  impaired,  and  varioloid  may  then  exhibit  as  severe  a  form  as 
ordinary  smallpox.     In  some  instances  it  is  fatal. 

The  term  varioloid  is,  as  has  been  stated,  applied  to  cases  of  variolous 
disease  if  there  have  been  previous  vaccination.  It  is  also  applied  by 
writers  to  second  attacks,  Avhether  the  first  occurred  from  infection  or 
from  variolous  inoculation,  but  such  cases  are  rare. 

Mode  of  Death. — Death  in  smallpox  occurs  in  several  different 
ways.  The  most  fatal  period  is  the  pustulai-.  Feeble  children  not 
infrequently  die  from  exhaustion  at  or  about  the  time  that  the  pustules 
attain  their  greatest  size.  The  eiuption  ajipears  and  becomes  developed 
as  usual,  but  there  are  evidences  of  weakness  in  the  ])atient,  and  sud- 
denly the  progress  of  the  vesicle  or  pustule  ceases.  It  begins  to  sub- 
side, and  its  walls  shrivel.  There  is  evidently  absorption,  in  part,  of 
the  liquid  contents.     These  phenomena  are  of  the  gravest  character. 


COMPLICATIOXS.  279 

Death  is  the  common  result,  and  within  twenty-four  hours.  In  other 
cases  death  occurs  from  apnoea,  Tlie  pock  increasing  in  size  in  the 
larynx  and  trachea,  obstructs  inspiration,  or  there  may  be  tlie  formation 
of  a  pseudo-membrane,  as  in  true  croup.  This  is  not  an  unusual  mode 
of  death  in  young  children,  in  whom  the  calibre  of  the  larynx  and 
trachea  is  small.  Sometimes  convulsions  and  coma  occur  in  the  last 
hours  of  life.  In  other  cases  the  stage  of  desquamation  is  reached,  but 
convalescence  does  not  occur.  The  patient  each  day  becomes  more  anj^mic 
and  feeble,  and  finally  death  results  from  failure  of  the  vital  powers. 
Again,  after  smallpox  has  run  its  course,  purpura  hemorrhagica  may  be 
developed.  Hemorrhages  occur  from  the  gums,  throat,  nostrils.  Blood 
is  vomited,  and  evacuated  in  the  stools.  I  have  known  death  to  occur 
in  all  these  ways,  but  that  from  purpura  is  least  frequent.  Sometimes, 
as  in  scarlet  fever,  death  occurs  suddenly  and  unexpectedly  in  con- 
fluent, and  even  in  discrete  variola,  when  the  pre\ious  symptoms  had 
apparently  been  favorable.  The  patient  is  overpowered  by  the  intensity 
of  the  virus. 

Anatomical  Characters. — In  those  who  have  died  of  variola,  Avith- 
out  inflammatory  or  other  complication,  the  heart-clots  have  been  found 
small,  dark,  and  soft.  The  blood  is  dark  and  thin.  The  vessels  of 
tlie  brain  and  its  membranes  are  injected,  so  that  numerous  red  points 
aj)pear  on  the  cut  surface  of  this  organ.  The  vessels  of  the  lungs  and 
the  abdominal  organs  are  congested,  while  the  muscles  present  a  deep 
red  color.  The  variolous  eruption  penetrates  more  deeply  than  that 
of  any  other  exanthematic  fever.  It  has  been  stated  elsewhere  that  it 
occurs  not  only  on  the  skin,  but  often  on  the  surface  of  the  mouth, 
fauces,  and  air-passages.  The  nnicous  membrane  in  these  situations  is 
frequently  also  the  seat  of  catarrhal  inflammation,  being  thickened  and 
softened,  and  in  some  parts,  as  the  larynx,  a  pseudo-membrane  is  occa- 
sionally produced,  as  in  croup. 

The  eruption  very  seldom,  perhaps  never,  appears  upon  the  gastro- 
intestinal surface,  but  the  solitary  follicles  and  patches  of  Peyer  are 
often  enlarged,  as  in  some  other  zymotic  affections.  The  liver,  spleen, 
and  kiilneys  are  commonly  congested  in  those  who  have  died  of  variola. 
1'lie  spleen,  especially,  is  increased  in  volume  and  softened;  the  kidneys 
are  enlarged,  as  from  commencing  nephritis,  and  sometimes  softened. 

The  minute  structure  of  the  pock  is  described  by  Killietand  liarthez, 
and  others.  The  vesicle  is  niultilocular,  consisting  of  at  least  five  or 
six  coni]»artmcnts,  Avith  distinct  ])artitions.  Its  centre  is  united  by 
fibrous  Ijands  to  the  derm  beneath,  which  union  gives  rise  to  tlie  umbili- 
cated  apjiearancc.  The  giving  way  of  these  minute  bands  in  the  pustular 
stage  occurs  Avhen  the  form  changes  from  the  umbilicated  to  the  convex. 
In  the  pustular  stage  also,  according  to  some,  a  flbrinous  formation  occurs 
within  the  pustuhr,  according  to  others,  this  substance  is  of  the  nature 
of  the  epidermis,  presenting  the  ap|)ea  ranee  of  the  cuticle  when  macerated. 
Mixed  with  this  e])idermic  or  fdjrinous  formation  are  pus-cells. 

(JoMi'LiCATiONS. — There  are  several  different  complications  of  variola. 
One  is  salivation.  This  is  common  in  the  adult;  but  rare  in  the  child. 
AVhcn  it  occurs  in  the  child,  it  is  sli";ht,  commencin'i  Avith  or  about  the 


280  VARIOLOID. 

time  of  the  eruption,  and  disappearing  in  from  one  to  four  or  five  days. 
Ophthalmia  is  another  complication.  Simple  conjunctivitis,  often  quite 
intense,  may  occur  in  consequence  of  pustules  developed  under  the  lids. 
This  inflammation  subsides  without  injury  to  the  eye,  as  the  primary 
disease  abates.  A  more  serious  inflammation  occurs  at  an  advanced  stage 
of  variola,  commencing  in  or  near  the  desquamative  period.  This  p)'o- 
duces  more  or  less  chemosis,  and  sometimes  opacity  or  ulceration  of  the 
cornea.  A  similar  inflammation  may  occur  in  the  ear,  giving  rise  to  otor- 
rhoea,  and  even,  in  some  patients,  to  rupture  of  the  drum  of  the  ear. 
Abscesses  in  the  subcutaneous  connective  tissue  have  been  occasionally 
observed,  especially  in  the  confluent  form.  Subcutaneous  infiltration  and 
feebleness  of  constitution  favor  their  occurrence.  Suppuration  within  the 
joints  is  a  somewhat  rare  complication  or  sequel,  rendering  convalescence 
protracted,  if,  indeed,  the  case  be  not  fatal. 

M.  Beraud  has  published  a  memoir  to  show  that  orchitis  in  the  male 
and  ovaritis  in  the  female  may  complicate  variola.  These  inflannnations 
are  believed  to  be  accomj)anied  by  a  small  and  imperfect  variolous  erup- 
tion upon  the  tunica  vaginalis  and  the  peritoneal  covering  of  the  ovary. 
Trousseau  states  that  he  has  often  met  this  complication  in  the  male, 
since  his  attention  was  called  to  it.  It  is  mild,  and  subsides  with  the  dis- 
appearance of  tlic  eruption.  Laryngitis,  simi)le  or  dij)htheritic,  bronchitis, 
pneumonia,  pharyngitis,  purpuric  hemorrhages,  gangrene  of  the  mouth 
or  other  parts,  oedema  pulmonum,  and  oedema  glottidis  are  occasional 
complications,  some  of  which  are  frequent,  others  rare. 

Progno.sis. — This  depends  on  the  age,  vigor  of  system,  form  of  the 
disease,  and  the  presence  or  absence  of  complications.  The  younger  the 
child,  the  greater  the  danger.  Trousseau  says:  "Confluent  variola,  and 
even  discrete  variola,  are  almost  always  fatal  in  individuals  less  than  two 
years  old."  Above  the  age  of  three  or  four  yeai'S  discrete  variola  usually 
ends  favorably,  but  the  confluent  form  is  still,  as  a  rule,  fatal.  Varioloid 
in  the  child  is  a  mild  disease,  terminating  favorably  in  a  large  propor- 
tion of  cases.  It  is  milder  at  this  age  than  in  the  adult,  on  account  of 
the  more  recent  period  of  vaccination.  If  varioloid  be  severe,  and  the 
eruption  abundant  in  a  child  Avho  has  been  vaccinated,  it  is  probable  that 
the  vaccination  was  spurious. 

It  is  not  necessary,  from  what  has  been  said,  to  specify  the  favorable 
prognostic  signs.  The  unfavorable  prognostics  are,  great  violence  of 
the  initial  symptoms;  early  appearance  of  the  eruption ;  an  abundant 
eruption,  especially  if  pale,  and  without  swelling  of  the  surface;  rapid 
decline  of  the  eruption  in  the  vesicular  or  pustular  stage,  hemorrhagic 
eruption,  or  hemorrhages  from  the  surfaces;  fever  continuing  after  the 
appearance  of  the  eruption ;  diarrhoea  persisting  beyond  the  third  or  fourth 
day;  delirium  or  great  drowsiness;  a  frequent  and  feeble  pulse;  and, 
finally,  obstructed  respiration — if  slow,  indicating  a  pseudo-membrane 
or  variolous  eruption  in  the  larynx  or  trachea;  if  rapid,  indicating  bron- 
ciiitis  or  pneumonia. 

Diagnosis. — The  diagnosis  cannot  be  made  with  certainty  prior  to  the 
eruptive  stage.  If,  however,  smallpox  be  prevalent,  if  the  pntient  have  not 
been  vaccinated,  and  the  symptoms  which  pertain  to  the  penoU  of  inva- 


TREATMENT.  281 

sion  be  present,  as  headache,  pain  in  small  of  back,  repeated  vomiting, 
drowsiness,  and  perhaps  convulsions,  there  is  ground  for  the  gravest  sus- 
picion. If  in  addition  to  these  symptoms,  reddish  points  begin  to  appear 
on  the  second  or  third  day,  the  diagnosis  may  be  made  witli  confidence. 
At  this  early  period,  even  before  there  is  any  distinct  cutaneous  erup- 
tion, ash-colored  spots  may  sometimes  be  observed  on  the  buccal  or 
faucial  surface,  the  commencement  of  the  variolous  eruption ;  these  pos- 
sess considerable  diagnostic  value. 

The  scarlatiniform  efflorescence,  in  the  first  stage  of  variola,  sometimes 
leads  to  the  belief  that  the  disease  is  scaidet  fever.  The  absence  of  the 
pharyngitis,  and  the  appearance  of  the  variolous  eruption  soon  after  the 
efflorescence,  correct  the  diagnosis.  Smallpox  has,  in  the  beginning  of 
the  eruptive  period,  sometimes  been  mistaken  for  measles.  The  points 
involved  in  the  differential  diagnosis  have  been  presented  in  treating  of 
that  disease.  After  the  development  of  the  eruption,  it  may  be  mistaken 
for  varicella.  The  eruption  of  varicella,  is,  however,  preceded  by  symp- 
toms which  are  milder  and  of  shoi'ter  duration,  and  its  appearance  is 
different.  It  is  irregular,  instead  of  round ;  is  not  umbilicated,  and  it 
d:)es  not  have  the  round,  inflamed,  and  indurated  base  Avhich  character- 
izes the  variolous  eruption.  The  eruption  of  ecthyma  is  sometimes  um- 
bilicated, but  the  symptoms  of  ecthyma  and  variola,  and  the  progress  of 
the  eruptions  in  the  two  diseases,  are  very  different. 

Treatment. — Smallpox,  like  the  other  essential  fevers,  is  self-limited, 
and  therefore  the  constitutional  treatment  should  be  sustaining  and  pal- 
liative. In  the  first  stages  of  the  disease,  the  diet  should  be  simple; 
gentle  laxatives  and  refrigerant  drinks  are  required  if  there  be  much 
febrile  excitement.  Lemon-.idc  is  a  grateful  drini<,  and  maybe  given  in 
moilerate  qiuintity.  Spiritus  mindereri  in  carbonic  acid  water  may  be 
allowed.  As  the  disease  advances,  more  nutritious  food  should  be  recom- 
mendcrl;  and  in  severe  cases  carbonate  of  ammonium,  and  even  alco- 
holic stimulants,  are  re(|[uired. 

As  conlhient  smallpox  is  nearly  always,  and  the  discrete  form  often 
fital  in  iiifluicv,  the  physician  should  carefully  watch  the  progre-s  of  the 
case  in  the  infant.  By  judicious  treatment,  some,  in  this  period  of  life, 
may  be  saved,  who  otherwise  would  perish.  In  the  infant  depressing 
measures  should  be  avoided.  A  laxative  may  be  given,  at  first,  if  there 
be  much  fever,  and  the  bowels  are  constipiitetl ;  but  the  diet  should  be 
nuti'itious,  and  many  soon  rr(juire  tonics  and  stimuhints.  .  If  the  pulse 
become  more  fre<[uent  and  feeble,  or  if,  Avith  frecpiency  of  the  ])ulsc,  the 
face  and  extremities  become  cool ;  or,  in  the  vesicular  or  ])ustular  stage, 
the  eruption  suddenly  subside,  alcoholic  stimulants  must  be  immediately 
employed,  or  tlie  patient  dies. 

Such  is  an  outline  of  the  constitutional  treatment  required  in  small- 
pox. Sydcidinm  inculcated  a  mode  of  treatment  which  experience  has 
shown  to  1)0  injurious  in  infancy  and  childhood.  lie  had  observed  that 
the  severity  of  the  disease  was  ordinarily  proportionate  to  the  amount 
of  eruption,  and  concluded  from  this  fact  that  measures  which  retarded 
the  development  of  the  eruption  were  salutary ;  cold  drinks,  a  cold 
apartment,  scanty  covering  of  the  body,  cathartics  that  caused  deriva- 
tion cf  the  blood  froni  the  surface,  even  sometimes  the  abstraction  of 


282  VARIOLOID. 

blood,  were  considered,  according  to  Sydenham's  theory,  to  be  useful 
as  means  of  preventing  full  development  of  the  eruption. 

Sydeidiam's  treatment,  however  appropriate  it  might  sometimes  be  in 
case  of  robust  adults,  is  unsuitable  for  children,  because  they  do  not, 
as  a  rule,  tolerate,  in  this  disease,  measures  which  reduce  the  strength. 
Moreover,  smallpox  is  rendered  more  dangerous  by  Avhat  Rilliet  and 
Barthez  designate  perturbating  treatment — treatment  which  renders  it 
abnormal.  '  The  regular  appearance  and  development  of  the  eruption 
are  requisite  in  order  that  the  case  may  progress  favorably.  On  the 
other  hand,  the  opposite  plan  of  treatment,  Avhich  families,  if  left  to 
themselves,  are  apt  to  adopt — namely  the  employment  of  measures  to 
promote  perspiration,  as  hot  drinks,  and  confinement  in  a  heated  room — 
is  also  injurious. 

The  j)atient  should  be  kept  in  a  temperature  such  as  he  has  been  ac- 
customed to,  and  such  as  is  agreeable  to  him;  his  diet  should  be  simple 
and  nutritious ;  laxative  medicine  should  only  be  given  to  procure  the 
natural  evacuations.  In  smallpox,  as  in  all  infectious  diseases,  free 
ventilation  of  the  apartment  is  required. 

While  the  general  eruption  should  not,  as  a  rule,  be  interfered  with, 
it  is  proper  to  endeavor  to  diminish,  so  far  as  possible  the  size  of  the 
pocks,  on  parts  exposed  to  view,  so  as  to  prevent  disfigurement.  Pro- 
fessor Flint,  in  his  Treatise  on  the  Practice  of  Medicine,  has  published 
an  excellent  summary  of  the  various  measures  which  have  been  recom- 
mended for  accomplishing  this  end.  First:  The  opening  and  breaking 
up  of  the  vesicle  by  means  of  a  fine  needle.  This  is  tedious  practice  in 
confluent  variola,  but  it  can  readily  be  performed  in  the  discrete  form — 
at  least  as  regards  the  vesicles  upon  the  face.  This  treatment  was  pro- 
posed by  Rayer,  and  it  is  recommended  by  many  who  have  tried  it. 
Secondly :  After  the  evacuation  of  the  liquid,  the  cauterization  of  the 
vesicle  by  a  pointed  stick  of  nitrate  of  silver.  Rilliet  and  Barthez  say, 
in  reference  to  this  mode  of  ti'catment,  "  Individual  cauterization  of  the 
pustules  is,  on  the  other  hand,  an  almost  infallible  means  of  causing 
them  to  abort.  To  be  successful,  it  is  necessary  to  penetrate  into  the 
interior  of  the  pustule  with  a  pointed  crayon  of  nitrate  of  silver  in  order 
to  cauterize  the  derm.  ...  It  is  only  the  first  or  second  day  of 
the  eruption  that  it  (cauterization)  has  certain  success;  nevertheless, 
we  have  often  seen  it  succeed  the  third  or  the  fourth  day,  or  even  the 
fifth." 

Thirdly :  The  application  of  tincture  of  iodine  once  or  twice  daily 
over  the  eruption  when  in  the  papular  stage.  Some  writers,  who  have 
employed  iodine,  state  that  it  does  not  prevent  pitting  but  diminishes  it. 
Its  favorable  effects  are  produced  by  coagulating  the  contents  of  the  papule. 
Fourthly:  The  exclusion  of  light  and  air  by  means  of  a  ])laster.  A 
mixture  containing  tannate  of  iron  has  been  employed  for  this  purpose 
in  one  of  our  hosj)itals.  This  produces  a  black  mask.  Light  and  air 
may  also  be  excluded  by  smeai-ing  the  face  with  sweet  oil,  and  dusting 
twice  daily  upon  the  oiled  surface  a  powder  containing  equal  parts  of 
subnitrate  of  bismuth  and  prepared  chalk.  Fifthly :  The  application 
of  mild  mercurial  ointment  upon  the  face  or  other  parts  of  the  surface, 
where  it  is  desirable  to  render  the  eruption  abortive.     This  mode  of 


VACciiSriA.  283 

treatment  does  diminish  the  size  of  the  vesicles  and  tlie  pitting,  but  I 
should  not  recommend  it  for  children,  I  have  known  in  the  adult  severe 
mercurialization  from  its  employment  for  four  or  five  days,  and,  though 
young  children  do  not  exhibit  so  readily  the  effects  of  mercury,  the 
use  of  the  ointment,  unless  for  a  very  limited  period,  increases,  in  my 
opinion,  their  feebleness,  and  diminishes  the  chance  of  their  recovery. 
Calamine  made  into  a  paste  with  sweet  oil  is  said  to  be  equally  effectual 
Avith  mercurial  ointment,  and  it  produces  no  constitutional  effect.  Its 
effect  is  obviously  similar  to  that  of  the  bismuth  and  chalk  employed 
with  sweet  oil  as  stated  above.  Also,  I  have  employed  pulverized 
charcoal  made  into  a  thm  paste  with  sweet  oil  or  glycerine,  and  applied 
daily  or  twice  daily  to  the  face.  It  effectually  excludes  the  light,  and 
the  result  appeared  to  be' good  as  regards  pitting,  but  it  is  a  disagreeable 
application.  Curschmann  recommends  as  preferable  to  any  of  these 
methods,  the  use  of  iced  compresses  to  the  face  and  hands.  The  pain, 
redness,  and  swelling  are  diminished  by  their  use,  but  without  change 
in  the  copiousness  of  the  eruption.  [Ziemsser^'s  Encyelop.)  If  fissures 
or  excoriations  occur,  an  application  may  be  made  of  oxide  or  carbonate 
of  zinc  in  glycerine,  one  drachm  to  the  ounce. 

The  prevention  of  smallpox,  so  far  as  practicable,  is  one  of  the  im- 
portant incidental  duties  of  the  physician.  Isolation  of  the  patient, 
and  precautions  in  reference  to  his  clothes  and  bedding,  are  imperatively 
required,  so  great  is  the  contagiousness  of  this  disease.  The  only 
certain  means  of  prevention  is  vaccination,  and  providentially  the  in- 
cubative period  of  the  vaccine  disease  is  less  than  that  of  variola. 
Therefore,  smallpox  may  be  prevented  after  the  virus  is  received  in 
the  system,  by  timely  and  successful  vaccination.  Vaccination,  at  any 
period  between  the  time  of  exposure  and  the  commencement  of  the 
symptoms  of  invasion,  will  either  prevent  the  occurrence  of  smallpox 
or  modify  it.  If  the  symptoms  of  invasion  have  already  commenced,  it 
is  uncertain  whether  it  produces  any  modifying  effect. 


CHAPTER  Y. 

VACCINIA. 

VaccTXTA  is  a  mild  eruptive  disease,  whicli  occasionally  occurs  among 
cattle,  and  has  been  propagated  from  them  to  man.  It  is  characterized 
by  the  appearance  upon  the  surface  of  one  or  more  papules,  which  soon 
become  vesicular,  an<l  then  pustular.  It  is  communicable  by  contact, 
but,  unlike  the  other  eruj)tive  fevers,  it  is  not  contagious  through  the  air. 
It  is  ino(;ulable,  both  by  the  liquid  continued  in  the  vesicle,  which  is 
designated  vaccine  lymj)h,  and  by  the  scab  which  results  from  the  ilesic- 
cation  of  the  pustule. 


284  VACCINIA. 

To  Gloucestershire,  England,  the  honor  belongs  of  discovering  and 
utilizing  the  fact  that  vaccinia,  a  mild  and  conij)aratively  harmless  dis- 
ease, is  transmissible  from  the  cow  to  man,  and  that  it  attbrds  protection 
from  smallpox.  It  appears  that  a  vague  opinion  prevailed  among  the 
farmers  of  this  dairying  section,  that  a  disease,  which  has  since  been 
designated  vaccinia,  was  occasionally  received  from  the  cow  in  milking, 
the  virus  passing  from  a  pustule  on  the  teat  to  a  sore  or  chap  on  the 
hand  of  the  milker,  and  that  those  who  thus  contract  the  disease  receive 
imuuinity  from  smallpox.  As  usually  happens  with  important  discov- 
eries, so  slow  of  apprehension  is  the  human  intellect,  these  people,  to 
whom  Providence  had  revealed  a  most  important  fact,  were  blind  to  its 
real  value.  Finally  in  the  year  1724,  Benjamin  Jesty,  whom  the  world 
has  not  sufficiently  honored,  "an  honest  and  upright  man,"  according 
to  his  epitaph,  a  farmer  of  Uloucestershire,  had  the  courage  to  vaccinate 
his  wife  and  two  children.  His  excellent  moral  character  did  not  shield 
him.  He  was  regarded  by  his  neighbors  as  an  inhuman  brute,  who  had 
performed  an  experiment  on  his  own  family,  the  tendency  of  which 
might  be  to  transform  them  into  beasts  Avith  horns. 

This  first  essay  in  vaccination  appears  to  have  been  entirely  successful, 
but  the  prejudice  against  the  operation  continued.  A  fifth  of  a  century 
passed,  during  which  there  was  no  extension  of  the  benefits  of  this  great 
discovery.  At  last,  toward  the  close  of  the  last  century.  Dr.  Edward 
Jenner,  a  physician  of  Gloucestershire,  an  inoculator  of  his  district, 
began  to  investigate  this  disease  of  the  cow,  about  which  little  was 
known,  and  the  grounds  for  the  belief  that  it  afforded  protection  from 
smallpox.  Fortunately  for  the  world,  Jenner  had  been  educated  uiuler 
John  Hunter,  and  had  learned  from  his  great  master  to  study  nature 
rather  than  books,  to  be  guided  by  experience  and  observation  rather 
than  by  the  dogmas  of  his  predecessors  or  of  the  schools. 

Jenner  performed  his  first  vaccination  on  the  14th  of  May,  1796, 
twenty-two  years  after  Benjamin  Jesty  had  lost  his  good  name  among 
his  neighbors  by  vaccinating  his  own  family.  The  populai'izing  of 
vaccination,  mainly  through  Jenner's  perseverance,  affords  one  of  the 
most  interesting  and  instructive  chapters  in  the  history  of  medical 
science.  How  he  went  up  to  London,  full  of  the  importance  of  the  dis- 
covery, and  was  there  advised  by  his  medical  friends  to  desist  from  his 
wild  schemes,  lest  he  should  injure  the  reputation  Avhich  he  had  gained 
from  a  creditable  paper  on  the  habits  of  the  cuckoo;  how  he  was  finally 
allowed  to  vaccinate  in  hospital  wards,  and  gained  some  adherents  to 
the  new  faith  among  the  leading  physicians  of  the  metropolis ;  and, 
finally,  how,  as  the  claims  of  vaccination  began  to  be  recognized,  at 
the  close  of  the  last  century  and  commencement  of  the  present,  a  most 
acrimonious  discussion  arose,  which  filled  all  the  medical  journals  of  that 
period.  The  oi)ponents  of  vaccination  resorted  to  every  device  to  pre- 
vent the  acceptance  of  Jenner's  views.  They  attempted  to  prejudice 
the  people  against  them  by  specious  arguments,  by  ridicule,  and  even 
by  caricatures.  One  of  the  leading  journals  contained  the  picture  of  a 
cow  covered  with  sores,  and  devouring  children,  and  it  was  urged  that 
vaccination  w'as  a  bestial  operation,  degrading  man  to  the  level  of  the 


VACCINIA.  285 

brute.  But  the  truth  had  gained  a  firm  hold,  and  the  practice  of  vac- 
cination extended. 

The  discovery  of  vaccinia,  and  of  its  protective  power,  cannot  be  too 
hiixhlj  appreciated.  It  ha.s,  probably,  done  more  to  relieve  human 
suffering  than  any  other  discovery  of  the  last  one  hundred  years,  unless 
Ave  except  that  of  anaesthetics,  and  more  to  save  human  life  than  any 
other  instrumentality  of  a  purely  physical  kind. 

The  fact  was  established  in  the  time  of  Jenner,  that  the  virus  of 
smallpox  inoculated  in  the  cow  produced  vaccinia,  which,  in  its  propa- 
gation back  to  man  never  returned  to  its  original  form,  but  always  re- 
mained vaccinia.  Moreover,  Jenner  believed  that  the  disease  known  in 
the  horse  as  the  crease  was  identical  in  nature  with  vaccinia  in  the  cow. 
He  failed,  however,  in  his  experiment  to  communicate  vaccinia  from  the 
horse,  but  other  experiments  have  been  more  successful.  In  1801,  a 
Dr.  Lov,  of  the  county  of  York,  England,  met  two  cases  of  vaccinia  in 
persons  who  had  taken  care  of  a  horse  affected  with  the  grease,  and, 
from  the  lymph  which  he  obtained,  Avas  able  to  produce  vaccinia  in  the 
cow.  In  1805,  Yiborg,  a  Danish  veterinary  surgeon,  after  many  fail- 
ures, succeeded  also  in  communicating  vaccinia  to  the  cow  by  means  of 
the  virus  taken  from  a  horse. 

From  this  time  little  light  Avas  throAvn  on  this  subject  till  Avithin  the 
last  tAventy  years.  Althougli  Loy  and  Viborg,  and  perhaps  a  few 
others,  had  recorded  their  success,  other  experimenters  had  failed  to  com- 
miniicate  vaccinia  from  the  horse.  In  the  absence  of  additional  cases 
the  profession  began  to  question  whether  there  might  not  have  been 
some  error  in  the  obserA^ations  of  the  gentlemen  whose  names  I  haA^e 
mentioned,  and  Avhetlier  a  disease  identical  Avith  A'accinia  occurred  in  the 
horse,  or  a  diease  Avhich  might  communicate  vaccinia  to  the  coav  or  to 
man,  Avas  still  regardetl  as  undetermined. 

Observations  confirmatory  of  those  of  Loy  and  Viborg  Avere  at  length, 
hoAvever,  made,  Avhich  nmst  be  regarded  as  conclusive.  In  1856,  in  the 
department  of  L'Eure-et-Loir,  France,  M.  Pichot  Avas  consulted  by  a 
boy  Avho  had  on  the  back  of  his  liands  vaccine  pustules,  Avhich  had  ap- 
parently reached  the  eightli  or  ninth  day.  He  had  not  taken  care  of  nor 
been  in  contact  Avith  a  coav,  but  had  a  few  days  before  taken  care  of  a 
horse  affected  with  the  grease.  Vaccination  Avas  performed  by  means 
of  the  lymph  taken  from  these  pustules,  and  genuine  vaccinia  Avas 
produced. 

Again  in  18G0,  an  epidemic  prevailed  among  the  horses  in  Ricmes 
and  Toulouse,  France.  A  mare  sickened  Avith  the  disease,  and  there 
Avas  swelling  of  the  hough,  Avith  discharge  of  sanious  matter.  M.  Dela- 
fosse  A'accinated  tAvo  cows  Avith  this  matter,  and  connnunicated  genuine 
vaccinia.  This  epidemic  was  believed  by  the  veterinary  surgeons  to  be 
an  eruptive  fever,  differing  in  its  nature  somewhat  from  the  disease  or 
diseases  Avhich  have  ordinarily  been  designated  the  grease.  It  has  been 
conjectured  that  two  or  more  distinct  affections  of  the  horse  have  the 
same  appellation,  one  of  Avhich,  it  is  noAvadmitte(^  is  identical  Avith  vac- 
cinia of  the  COAV,  and  may  communicate  it ;  and  the  reason  Avhy  so  many 
experimenters  liave  failed  to  vaccinate  the  coav  from  the  horse  is  that 
they  have  used  the  virus  of  the  Avrong  disease,  or  liave  taken  virus  from 


286  VACCINIA 

horses  which  had  been  affected  with  the  true  disease,  hut  from  ulcers 
which  had  k^st  tlieir  si)ecific  character. 

Prior  to  the  time  of  Jenner  variolous  inoculation  was  practised  in  most 
civilized  countries,  since  variola  ])roduced  in  this  Avay  was  fouml  to  be 
milder  thanwdien  arising  from  infection.  This  practice  is  now  obsolete; 
forbidden  in  some  places  by  legislative  enactments.  It  is  superseded  by 
vaccination.  Vaccination,  or  the  introduction  of  vaccine  lymph  into 
the  system,  is  quickly  and  conveniently  j)erforraed  by  scarifying  with  a 
lancet,  and  rublting  into  the  incisions  the  lymph,  or  a  little  of  tiie  scab 
pulverized  and  dissolved  in  a  drop  of  cold  water.  It  may  also  be  per- 
formed by  scraping  off  the  epidermis  with  the  edge  of  the  instrument  till 
the  blood  begins  to  ooze ;  and  also,  though  with  less  certainty  of  success, 
by  puncturing  the  skin  with  the  point  of  the  lancet,  or  by  an  instru- 
ment called  the  vaccinator.  The  scab  should  never  be  employed  when 
it  is  possible  to  obtain  pure  lymph,  since  it  contains  animal  matter  apart 
from  the  virus,  and  may  be  the  medium  through  which  other  diseases 
may  be  communicated.     Besides  it  is  much  less  active  than  pure  lymph. 

If  the  child  have  a  vascular  nievus,  this  may  be  selected  as  the  point  of 
vaccination.  Unless  of  large  size,  it  can  usually  be  cured  by  the  in- 
flammation which  vaccinia  produces.  Statistics  collected  by  Simon,  as 
well  as  Marson,  show  that  of  those  who  contract  varioloid,  the  larger 
the  number  of  vaccine  cicatrices  the  milder  the  disease,  and  the  less  the 
proportionate  number  of  deaths.  In  Simon's  statistics  of  those  who 
stated  that  they  had  been  vaccinated,  but  who  presented  no  cicatrix, 
21f  per  cent,  died;  of  those  who  had  one  cicatrix,  7^  per  cent,  died; 
of  those  who  had  two,  4|-  per  cent,  died;  of  those  Avho  had  three,  If 
per  cent,  died ;  while  of  those  who  had  four  or  more  cicatrices,  only  f 
per  cent.  died.  These  statistics  would  seem  to  indicate  the  propriety  of 
vaccinating  in  several  places.  But,  so  far  as  appears,  when  two  or  more 
cicatrices  were  observed,  the  patients  may  have  been  vaccinated  at  differ- 
ent times,  at  intervals,  perhaps  of  several  years,  and  if  so,  the  inference 
would  not  follow  that  more  complete  protection  is  produced  by  vaccinat- 
ing in  several  places  than  in  one.  Moreover,  if  vaccination  be  performed 
in  the  usual  manner  by  several  incisions  on  the  arm,  and  the  virus  be 
fresh  and  active,  usually  two  or  more  distinct  vesicles  arise,  which  unite 
in  their  development  and  probably  protect  the  system  as  much  as  if  they 
were  separated  by  a  wider  space. 

Appearaxces — Symptoms. — In  genuine  vaccination  no  effect  is  ob- 
served, except  the  slight  inflammation  due  to  the  operation,  till  the  close 
of  the  third  day.  Then  the  specific  inflammation  commences.  This  is 
indicated  by  a  small  red  point,  at  first  scarcely  visible,  indurated  and 
slightly  elevated,  as  determined  by  the  touch,  rather  than  by  the  eye. 
This  increases,  and  on  the  fifth  day  the  cuticle  over  the  inflamed  part 
begins  to  be  raised  by  a  transparent  and  thin  liquid.  The  vesicle 
increases  in  diameter,  and  by  the  sixth  day  presents  an  umbilicated  ap- 
pearance, and  is  surrounded  by  a  faint  and  narrow  red  zone.  At  the 
close  of  the  eighth  day  the  vesicle  is  fully  developed.  Its  size  varies 
considerably.  It  is  usually  from  a  sixth  to  a  third  of  an  inch  in  di- 
ameter, and  oval  or  circular.  If  the  vaccination  have  been  performed 
by  incisions,  the  size  of  the  matured  vesicle  may  be  considerably  larger, 


A.XOMALIES,    COMPLICATIONS,    AST)    SEQUELS.  237 

and  its  shtipe  irregular,  in  consequence  of  the  union  of  two  or  more 
vesicles.  The  eruption  now  presents  a  whitish  or  pearl-colored  appear- 
ance, due  to  the  whiteness  of  the  cuticle,  and  the  transparence  of  the 
liquid  underneath.  If  the  vaccination  be  performed  by  incisions,  it  is 
not  unusual  to  observe  over  the  centre  of  the  vesicle,  and  adhering  to  it, 
a  small  yellowish  scab,  Avhich  has  resulted  from  the  scarification,  and 
Avhich  contains  none  of  tlie  virus. 

The  vaccine  vesicle,  like  that  of  variola,  consists  of  compartments, 
commonly  eight  or  ten,  with  complete  partitions,  so  that  there  is  no  inter- 
communieati(jn.  On  the  ninth  day  the  inflamed  areola  becomes  more 
distinct,  and  its  diameter  raj)idly  increases.  Its  color  is  deep  red,  its 
temperature  is  considerably  elevated,  and  it  is  accompanied  by  more  or 
less  induration  of  the  subcutaneous  tissue,  and  it  is  tender  to  the  touch. 
On  the  tenth  day  the  pock  has  reached  its  full  development.  The 
areola  then  extends  from  one  to  two  inches  away  from  the  vesicle,  be- 
coming fainter  at  its  outer  circumference,  and  gradually  disappearing  in 
the  healthy  skin.  The  shape  of  the  outer  circumference  of  the  areola 
is  irregular,  projecting  further  at  one  point  than  another,  though  its 
general  form  is  circular. 

On  the  tenth  day,  when  the  inflammation  has  reached  its  maximum, 
the  heat,  itching,  and  tenderness  in  and  around  the  pock  are  such  that 
the  child  is  often  feverish  and  restless.  Occasionally  the  glands  of  the 
axilla  become  swollen  and  tender.  In  other  cases,  in  which  there  is 
but  a  moderate  amount  of  inflammation,  the  constitutional  disturbance  is 
slight. 

At  the  close  of  the  tenth  day,  or  on  the  eleventh,  the  inflammation 
begins  to  decline ;  the  areola  becomes  narrower  and  then  disappears ; 
the  induration  and  tenderness  abate;  and  Avith  this  change  the  ])ustule 
desiccates,  its  li(piid  is  absorbed,  and  there  results  a  brownish  or  a  dark 
mahogany-colored  scab,  which  is  detached,  ordinarily,  between  the  four- 
teenth and  twenty-first  days.  The  cicatrix,  at  first  reddish,  like  all 
recent  cicatrices,  gradually  becomes  paler,  and  remains  whiter  than  the 
surrounding  integument.  It  presents  several  minute  depressions  or 
pits,  which  indicate  the  genuineness  of  the  vaccination. 

Tiie  theory  that  smallpox  becomes  vaccinia  by  passing  through  the 
heifer,  as  we  have  given  it  above,  has  for  many  years  been  un(lisj)uted. 
]Jut  recently  the  theory  has  been  promulgated  that  vaccinia  and  variola, 
instead  of  being  forms  of  the  same  disease,  are  essentially  distinct; 
that  when  the  heifer  is  inoculated  with  the  virus  of  smallpox  the  dis- 
ease which  is  produced  is  a  modified  smallpox  but  not  vaccinia,  whicii 
occurs  as  a  spontaneous  disease  among  cattle.  It  may  be  that  the  old 
theory,  which  no  one  doubted  until  recently,  is  wrong,  but  that  vacci- 
nation prevents  smallpox,  just  as  a  mild  attack  of  scarlet  fever  prevents 
a  severe  attack  of  the  same  disease,  shows,  in  my  opinion,  a  close  rela- 
tionship between  vaccinia  and  the  severe  malady  which  it  prevents. 
We  wait  for  more  conclusive  facts  in  support  of  the  new  theory,  l)efore 
accepting  it. 

Anomalie.-,  Co.mplications,  and  Sf.quel>. — The  vesicle  is  often 
broken,  accidentally,  or  by  the  nails  of  the  chihl.  If  the  top  of  the  vesi- 
cle be  destroyed,  or  most  of  the  compartments  be  opened,  the  inflamraa- 


288  VACCINIA. 

tiou  is  commonly  increased,  considerable  suppui-ation  occurs,  and  there 
results  a  large,  irregular,  yellowish  scab,  consisting  of  the  virus  mixed 
with  desiccated  pus.  This  scab  is  entirely  unreliable,  and  unfit  for  the 
purriose  of  vaccination,  though  the  protective  poAver  of  the  disease  is 
not  diminished  by  injury  of  the  vesicle,  even  if  it  be  totally  destroyed. 
The  cicatrix  wliich  results  from  extensive  injury  of  the  vesicle  is  a})t  to 
be  large,  and  without  the  indented  ])oints  which  characterize  the  normal 
cicatrix. 

In  rare  cases  when  the  inflammation  which  surrounds  the  vesicle  is 
intense  and  deep  seated,  suppuration  occurs  in  the  subjacent  connective 
tissue,  givin*''  rise  to  an  abscess.  This  abscess  is  commonly  of  small 
size,  but  it  increases  the  fretfulness  and  constitutional  disturbance  which 
attend  vaccinia.  This  subcutaneous  suppuration  occurs  most  frequently 
in  those  Avho  have  a  scrofulous  or  vitiated  state  of  system.  Inflamma- 
tion of  the  lymphatic  glands  of  the  axilla  I  have  spoken  of  as  not  in- 
frequent in  vaccinia.  This  sometimes  proceeds  to  suppuration,  produc- 
ing an  unpleasant,  though  not  serious,  complication. 

It  sometimes  happens  that  vesicles  appear  in  other  parts  besides  the 
points  where  the  virus  was  inserted.  These  supernumerary  vesicles 
commonly  occur  where  the  cuticle  has  been  removed  by  scalds  or  injuries. 

Trousseau  relates  the  case  of  an  infant  whom  he  had  vaccinated.  On 
the  eleventh  day  he  was  astonished  to  find  twenty-seven  vaccine  pustules 
on  the  face,  trunk,  and  limbs.  This  infant  bad,  however,  before  the  vac- 
cination, a  simple  non-specific  eruption  over  the  whole  body,  and  it  wa:^ 
believed  that  it  had  produced  these  vaccinations  by  transferi-ing  the 
lymph,  Avith  its  nails,  to  the  various  parts  where  the  cuticle  was  denuded. 

It  is  not  unusual,  also,  to  observe  minute  papules  appearing  on  parts 
of  the  surface  simultaneously  with  or  soon  after  the  vesicle,  and  in  a  few 
days  declining.     These  seem  to  be  abortive  vaccine  eruptions. 

One  of  the  most  serious  complications  is  erysipelas.  This  may  occur 
directly  from  the  operation,  or  from  the  inflammation  caused  by  the 
vesicle,  wdien  the  virus  possesses  no  deleterious  property  ;  and  again,  it 
may  result  from  some  unknown  element  in  the  virus.  It  may  occur 
immediately  after  the  operation,  when  it  commonly  prevents  the  working 
of  the  virus,  or  during  the  vesicular  or  pustular  stage;  or,  again,  after 
desiccation  and  separation  of  the  scab.  I  have  observed  it  at  all  these 
periods. 

Erysipelas,  occurring  as  a  complication  of  vaccinia,  is  invariably 
referred  by  the  friends  to  the  virus  employed,  and  the  physician  who  has 
had  the  misfortune  to  vaccinate  is  often  unjustly  blamed.  In  many  of 
these  cases  there  is  a  strong  predisposition  to  erysipelas  at  the  time 
of  the  vaccination,  and  the  oj)eration  or  the  inflammation  which  accom- 
panies the  normal  development  of  the  visicle  serves  simply  as  an  excit- 
ing cause.  Erysipelas  would  occur  as  soon  from  a  non-specific  sore  ; 
indeed,  we  not  infrequently  are  called  to  cases  of  this  disease  in  young 
children,  which  commence  from  non-specific  sores  upon  the  genitals,  or 
on  one  of  the  limbs.  That  the  fiult  is  not  in  the  virus  employed,  is 
evido.-.i  from  the  fact  that  other  children,  vaccinated  with  the  same,  have 
simple  uncomplicated  vaccinia. 

Sometimes,  on  the  other  hand,  the  cause  of  erysipelas,  Avhatever  it 


SUBSEQUENT    V  ACCIX  ATIONS.  289 

may  be,  exists  in  the  virus.  For  further  facts  in  reference  to  this  subject, 
the  reader  is  referred  to  our  remarks  on  erysipelas. 

The  fact  is  established  by  many  observations  that  syphilis  is  communi- 
cable by  vaccination.  The  symptoms  of  it  may  not  appear  till  vaccinia 
has  terminated,  or  for  a  little  time  subsequently,  but  it  then  constitutes 
a  very  serious  sequel.  A  physician  of  this  city,  Avell  known  in  this 
community  as  skilful  in  the  diagnosis  and  treatment  of  skin  diseases, 
and  therefore  not  likely  to  be  mistaken  as  regards  the  nature  of  the  dis- 
eases, states  that  he  communicated  syphilis  to  two  infants  by  vaccinating 
■with  the  same  scab.  Both  had  the  characteristic  syphilitic  eruption. 
In  January,  1868,  an  infant  was  brought  to  Prof.  Alonzo  Clark's  clinique, 
in  this  city,  having  syphilitic  rupia,  Avhich,  in  the  opinion  of  the  physi- 
cians present,  was  undoubtedly  the  result  of  vaccination. 

Trousseau  relates  the  case  of  a  young  woman,  eighteen  years  old,  who 
was  vaccinated  with  virus  taken  from  an  infant  apparently  in  perfect 
health.  The  vaccination  was  unsuccessful ;  but  twenty-tliree  days  subse- 
quently his  attention  was  called  to  an  eruption  Avhich  had  appeared  in 
two  places  on  the  woman's  arm,  corresponding  with  the  points  where  the 
virus  had  been  inserted.  The  eruption  was  that  of  ecthyma,  which,  by 
the  next  examination,  which  was  five  days  subsequently,  had  been  trans- 
formed into  rupia.  The  axillary  l^'mphatic  glands  were  tumefied  and 
indolent,  and  finally  roseola  appeared,  which  removed  all  doubts  as  to 
the  sypliilitic  character  of  the  disease.  There  was  syphilitic  infection, 
which  first  manifested  itself  in  the  points  where  vaccination  had  been 
])erf()rmed  (^Article  de  la  Vaccine).  It  is  not  ascertained  in  Professor 
(Jlark's  case,  nor  is  it  stated  in  Trousseau's,  whether  the  lymph  or  scab 
was  employed  for  vaccination.  There  can  be  little  doubt  that  the  pure 
lymph  never  communicates  anything  but  vaccinia,  and  if  by  vaccination 
any  other  disease  be  imparted,  a  little  blood  has  mingled  with  the  lymph, 
or  the  scab  has  been  employed. 

The  vesicle  in  genuine  vaccinia  is  sometimes  very  small,  not  having 
a  diameter  of  more  than  two  lines.  Occasionally  the  development  of 
the  vesicle  is  retarded.  It  does  not  appear  till  two  or  tln'ec  days  later 
than  the  usual  time,  or  even  a  longer  period. 

Vaccinia  is  modified  by  certain  diseases.  It  is  arrested  by  measles 
and  scarlet  fever,  pursuing  its  course  after  the  subsidence  of  the  exan- 
them.  On  the  other  hand,  it  sometimes  modifies  the  paroxysmal  cough 
of  pertussis,  but  only  during  the  time  when  the  pock  is  maturing,  Ecza- 
matous  eruptions  occasionally  occur  after  vaccinia,  as  they  often  do  after 
the  other  eruptive  fevers,  or,  if  already  present,  they  may  be  aggravated. 

Subsequent  Vaccinations. 

A  second  vaccination,  porfoimed  ])rior  to  the  ninth  day  after  the  first 
vaccination,  is  successful.  A  genuine  vaccine  eruption  results,  which 
is  smalk'r  the  inore  advanced  the  pi-imary  disease.  This  second  eruption 
ovei"tfikes  the  first.  On  the  ninth  d;iy  the  susceptibility  to  vaccinia  is, 
in  most  cases,  lost;  so  that  vaccination  performed  on  the  tentli,  or  sub- 
se(|uent  days,  is  unsuccessful. 

As  a  rule,  an  acute  contagious  disease  occurs  only  once  in  the  same 

IP 


290  VACCIXIA. 

individual.  Vaccinia  is  an  exception,  in  most  people,  after  a  few 
years,  it  can  be  produced  a  second  time;  and  cases  of  a  third  or  fourth 
successful  vaccination,  at  intervals  of  a  few  years,  are  not  uncommon. 
Now,  subsequent  cases  of  vaccinia  differ  from  the  first,  which  has  been 
described  above.  The  period  of  incubation  is  shorter,  and  the  vesicular, 
pustular,  and  desiccative  stages  succeed  each  other  more  rapidly,  so  tliat 
the  Avhole  period  of  the  disease  is  less.  The  variation  from  the  appear- 
ance and  course  of  the  first  vesicle  is  proportionate  to  the  degree  of  pro- 
tection which  the  first  vaccination  still  affords,  both  as  regards  smallpox 
and  vaccinia.  If  several  years  have  elajised  since  the  first  vaccination, 
and  the  protective  power  which  it  affords  is  nearly  lost,  the  second 
vaccinia  differs  but  little  from  the  first.  If,  on  the  other  hand,  the  first 
vaccination  still  afford  nearly  complete  protection,  the  result  of  the  second 
is  slight;  the  eruption  is  insignificant,  lacking  the  characteristic  aj)pear- 
ance  of  the  vaccine  vesicle,  resembling  a  common  sore,  and  disappearing 
■within  a  Aveek.  It  is  not  accompanied  by  the  inflamed  areola,  or  any 
appreciable  constitutional  disturbance. 

Vaccination  often  produces  no  result.  This  is  sometimes  due  to  the 
fact  that  the  lymph  or  scab  employed  is  useless.  It  has  spoiled  by  keep- 
ing, or  never  has  been  good.  In  other  cases  it  is  due  to  a  lack  of  suscep- 
tibility in  the  person.  Some  take  vaccinia  witli  difficulty,  and  only  after 
several  vaccinations ;  just  as  children,  though  fully  exposed,  often  fail 
to  take  measles  or  scarlet  fever,  on  account  of  a  condition  of  the  system 
which  prevents  the  reception  of  the  virus,  or  antagonizes  and  controls 
its  action.  In  some  instances,  after  vaccination,  an  eruption  is  produced, 
which  may  or  may  not  be  genuine;  but  it  immediately  becomes  purulent, 
and  is  soon  broken.  A  large  yellow,  uneven  scab  results,  having  none 
of  the  appearance  and  containing  little  or  none  of  the  vaccine  virus. 
This  scab,  as  well  as  the  liquid  matter  which  preceded  the  formation  of 
the  scab,  is  utterly  useless  for  the  purpose  of  vaccination,  and,  if  so 
employed,  will  probably  cause  a  sore  from  its  irritating  effect,  but  not  of 
a  specific  character.  If,  in  place  of  the  true  vaccine  vesicle,  the  eruption 
present  the  appearance  which  I  have  described,  namely,  that  of  a  pustule, 
soon  breakins  and  forming  a  large  irregular,  yellowish  scab,  the  vaccinia 
— if  it  be  correct  so  to  designate  it — must  be  considered  spurious.  A 
sore  has  been  produced  by  the  animal  matter  which  was  employed  in  the 
vaccination  along  with  the  virus,  which  has  modified  the  action  of  the 
virus,  and  probably  has  rendered  it  useless  as  a  means  of  protection  ;  or 
there  may  have  been  no  virus  inserted  with  this  animal  matter.  The 
physician  should  in  such  cases  insist  on  a  second  vaccination. 

Cases  like  the  above  are  of  frequent  occurrence,  and  the  parents  of 
the  child  are  often  satisfied  Avith  the  result.  They  see  an  eruption 
following  vaccniation,  accompanied  by  considerable  inflammation,  and 
leaving  a  cicatrix.  Unless  undeceived  by  the  physician,  they  are  apt  to 
remain  in  thebclief  of  the  child's  security,  until,  perhaps,  it  takes  small- 
pox. Such  cases,  obviously,  tend  to  diminish  the  confidence  which  the 
public  should  have  in  vaccination  as  a  means  of  protection  from  small- 
pox, and  on  account  of  their  frequent  occurrence  it  is  important  in  every 
case  that  the  physician  should  see  the  result  of  his  vaccination.  It 
has  been  proposed,  as  a  means  of  determining  the  genuineness  of  vaccinia, 


EETACCIXATIOX.  291 

to  revaccinate  when  the  eruption  begins,  and  if  the  first  be  genuine,  the 
second  will  overtake  it.  This  is  called  Brices  test ;  but  it  is  not  neces- 
sary, since  the  physician,  familiar  with  the  appearance  of  the  true  vesicle, 
can  determine  at  once  its  genuineness  by  the  sight. 


Protection  from  Vaccination — Revaccination. 

It  was  believed  by  the  early  advocates  of  vaccination  that  the  general 
performance  of  this  operation  would  soon  eradicate  smallpox  from  the 
communit3%  so  that  it  would  be  interesting  only  to  the  medical  historian 
as  a  scourge  of  past  ages.  This  result,  however,  is  not  .achieved.  As 
a  rule,  the  greater  the  benefit  of  any  measure  designed  to  ameliorate  the 
condition  of  mankind,  the  greater  and  more  numerous  are  the  obstacles 
which  diminish  its  effectiveness.  Science  is  full  of  examples  of  this. 
Fortunately  these  obstacles,  as  regards  vaccination,  are  not  such  as  to 
impair  the  confidence  of  physicians  in  its  protective  power,  and  it  is  not 
too  much  to  expect  that  this  simple  operation  Avill  yet  be  ths  means  of 
rendering  smallpox  a  disease  almost  unkiVown,  unless  in  its  modified 
form. 

Vaccination  should  be  performed  in  the  first  year  of  life.  In  rural 
districts  where  there  is  little  danger  of  exposure  to  smallpox,  it  may  be 
deferred  till  the  age  of  ten  or  twelve  months.  In  the  city,  on  the  other 
hand,  where  there  is  constant  intercourse  of  people,  and  where  contagious 
diseases  are  often  contracted  in  ignorance  of  the  time  and  place  of 
exposure,  an  earlier  vaccination  is  advisable.  Some  physicians  recom- 
mend performance  of  the  operation  as  early  as  the  age  of  four  or  six 
Aveeks.  The  objection  to  this  is,  that  if  erysipelas  occur,  so  young  an 
infant  is  apt  to  perish  from  it,  whereas  an  infant  three  or  four  months 
old  ordinarily  recovers.  For  this  reason  I  believe  that  the  most  suitable 
age  is  about  four  months  for  the  city  infant,  in  ordinary  times;  but  if 
smallpox  be  epidemic,  vaccination  should  bo  performed  at  an  earlier  age. 
I  have  vaccinated  even  the  newborn  infant  when  smallpox  had  broken 
out  in  adjoining  "apartments. 

Vaccinia  usually  extinguishes,  for  a  time,  the  susceptibility  to  small- 
pox. According  to  Mr.  Gintrac,  varioloid  does  not  occur  within  two 
years  in  those  who  have  been  vaccinated.  It  may,  however,  in  excep- 
tional instances,  occur  in  a  mild  form  within  a  few  months  after  vaccina- 
tion, Tlio  protection  aff'oriled  by  vaccination  gradually  diminishes  by 
time,  but  it  docs  not  probably,  as  a  rule,  cease  entirely.  Varioloid, 
however,  occurring  thirty  or  forty  years  after  a  successful  vaccination,  is 
apt  to  bo  severe,  and  it  may  even  be  fatal,  showing  that  it  has  been  but 
slightly  modified.  In  other  cases,  even  after  so  long  an  interval,  the 
sym|ttoms  pn^sent  a  degree  of  mildness  which  indicates  that  the  protec- 
tive power  of  the  vaccination  is  not  entirely  lost. 

If  a  second  vaccination  be  practised  soon  after  the  scab  from  the  first 
vaccination  has  fallen,  it  will  usually  produce  no  result,  but  in  other 
cases  it  gives  rise  to  a  little  redness,  swelling,  and  induration,  which 
show  that  vaccinia  has  been  reproduced,  though  in  a  very  mild  and 
insignificant  form.     It  is  probable  that  in  these  cases  varioloid  migiit 


292  VACCINIA. 

also  occur  by  exposure,  though  with  a  mihlness  corresponding  with  that 
of  the  vaccinia.  The  longer  the  period  after  the  first  vaccination,  the 
greater  the  number  of  those  in  whom  a  second  vaccination  is  effective, 
and,  as  has  already  been  stated,  the  greater  also  the  liability  to  the 
variolous  disease,  until  the  system  is  protected  by  a  second  vaccination. 
A  second  vaccination  should  be  jierfonned  about  the  sixth  or  eighth  _year, 
and  a  third  between  the  fifteenth  and  twentieth  years.  If  smallpox  be 
epidemic,  it  is  proper  to  vaccinate  all  who  have  not  been  vaccinated 
within  three  or  four  years. 

Selection  of  Virus. 

The  lymph  is  preferable  to  the  scab  for  vaccination,  provided  that  it 
can  be  obtained  fresh.  The  scab  is  more  easily  preserved,  and,  there- 
fore, if  the  lymph  and  the  scab  be  old,  the  latter  is  to  be  preferred.  The 
lymph  should  be  taken  on  the  fifth  day,  if  the  vesicle  be  sufficiently  de- 
veloped. It  may  also  be  taken  on  the  sixth,  seventh,  or  even  eighth 
day,  provided  that  the  areola  have  not  formed.  The  lymph  of  the  fifth 
day  acts  witli  greater  energy,  though  that  of  the  sixth  or  seventh  day 
is  not  much  inferior.  Lymph  obtained  after  the  formation  of  the 
areola  is  less  efficient,  though  it  may  communicate  the  genuine  disease. 

There  is  no  mode  of  vaccination  so  reliable  as  the  use  of  lymph  taken 
directly  from  the  arm  and  immediately  inserted — the  arm  to  arm  vacci- 
nation. Lymph  can  be  preserved  for  a  few  days  on  a  flattened  sui'flice 
of  whalebone,  or  the  segment  of  a  quill,  and  if  employed  within  a  week, 
it  will  usually  communicate  vaccinia  Lymph  may  be  preserved  a  longer 
period  between  two  surfaces  of  glass,  but  the  best  way  of  preserving  it 
is  in  capillary  glass  tubes.  The  end  of  the  tube  is  placed  within  the 
vesicle,  and  the  lymph  ascends  by  capillary  attraction.  When  a  suffi- 
cient quantity  is  received,  the  ends  are  sealed,  by  holding  them  for  a 
moment  in  a  ilaine.  Care  is  requisite  in  doing  this  so  as  not  to  heat  the 
lymph,  as  it  is  si)oiled  by  a  temperature  much  above  the  body.  When 
the  lymph  is  used,  the  ends  of  the  tube  are  broken,  and  by  blowing 
gently  through  it  a  sufficient  quantity  is  received  on.  the  point  of  a 
lancet. 

If  the  scab  be  genuine,  it  presents  a  dark  brown  or  mahogany  color, 
and  has  a  circular,  oval,  or  at  least  a  rounded  form  ;  it  is  firm,  or  com- 
pact, and  has  a  lustre.  Soft,  yellowish,  and  irregular  scabs  are  not  genu- 
ine, and  those  of  a  dull  appearance,  or  without  lustre,  have  usually 
spoiled  in  the  keeping.  The  scab  is  best  preserved  in  soft  beesAvax, 
which  excludes  tlie  air,  and  it  should  be  kept  in  a  cool  place.  It  is  the 
belief  of  many  that  the  vaccine  virus  gradually  becomes  weaker  by  pass- 
ing successively  through  the  human  system  (Oondie,  American  Journal 
of  the  3I('dieal  Sciences,  April,  18(35),  and  that  therefore  different  spe- 
cimens of  virus  work  with  different  energy,  according  to  the  degree  of 
removal  from  the  cow.  To  what  extent  this  view  is  correct  is  not  fully 
ascertained,  but,  certainly,  if  the  virus  employed  continue  to  produce  a 
small  vesicle,  attended  only  by  a  little  inflamm.ation.  there  is  reason  to 
believe  that  the  protection  which  it  imparts  is  less  than  that  from  virus 
which  works  with  greater  energy,  and  it  should  be  exchanged  for  such. 


VARICELLA.  293 

In  Xew  York  we  are  able  to  obtain  at  any  time  lymph  directly  from  the 
heifer.  It  has  never  passed  through  human  blood,  for  the  original  lymph 
came  from  cattle  in  one  of  the  provinces  of  France,  Avhere  vaccinia  was 
prevailing  epidemically.  The  popular  objection  to  vaccination  is  obvi- 
ated by  the  use  of  this  lymph,  but  it  works  with  great  energy,  produc- 
ing a  lai'ge  pock,  and  a  sore  which  is  often  a  month  in  healing.  I  have 
found  it  very  reliable,  and  prefer  to  use  it  in  ordinary  cases. 


CHAPTEE   YI. 

VARICELLA.    . 

Varicella,  chickenpox^  or  swinepox,  is  the  shortest  and  mildest  of 
the  eruptive  fevers.  It  is  highly  co_ntagious,  so  that  few  children  escape 
who  are  exposed  to  it.  Its  period  of  incubation  is  IVom  fifteenjo  seven- 
teciLjI.ays.  It  is  not  inoculable,  or  at  least  those  who  have  attempted  to 
inoculate  with  the  lymph  of  varicella  have  failed.  I  endeavored  to  com- 
municate the  disease  in  this  way  some  years  ago,  but  without  result.  It 
attacks  the  same  individual  but  once,  and  it  occurs  as  an  epidemic.  It 
has  been  thought^y  some  to  prevail  most  immediately  before,  during, 
or  after  epidemics  of  smallpox,  and  it  has  been  conjectured  that  it  is  a 
mollified  form  of  variola,  and  hence  its  name,  which  signifies  little 
variola.  This  idea  is,  however,  entertained  by  few,  and  it  is  opposed  by 
the  following  facts :  Varicella  may  occur  after  variola,  or  variola  after 
varicella,  without  any  modification,  and  the  two  diseases  are  very  dis- 
similar as  regards  gravity  of  symptoms  and  <lur;i,tion.  The  variolous 
disease,  whether  smallpox  or  varioloid,  often  occurs  in  the  adult;  vari- 
cella, on  the  other  hand,  is  a  disease  of  infancy  and  childhood.  I  have 
seen  one  adult  case,  which  I  recall  to  mind,  and  Professor  Flint  states 
that  he  has  also  observed  it,  but  its  occurrence  at  this  period  of  life  is 
rare.  Moreover,  varicella  and  variola  have  been  known  to  occur  simul- 
taneously in  the  same  individual.  Such  a  case  was  reported  by  M. 
Delpech,  in  a  memoir  published  in  1X40. 

Symptoms. — Varicella  usually  coiiunenccs  with  such  symptoms  as 
usher  in  ordinary  niildjfcbjile  attacks,  namely,  headache,  languor,  chilli- 
ness, and  sometimes  achhig  in  the  back  and  liml)s.  Fever  supervenes, 
AvTITch  is  usually  ino(lerate,  the  pulse  rising  perhaps  to  100  or  112,  and 
the  thermometer  showing  an  increase  of  temperature,  but  less  than  occurs 
in  the  other  eruptive  fevers.  These  symptoms  which  precede  the  erup- 
tion arc  sometimes  absent,  or  are  so  mild  as  to  escape  notice.  The  fever 
usually  ceases  on  the  seci^md  day,  but  it  may  return  on  the  following 
night.  The  a|ip(^te  is  rarcly^lost,  and  most  children  continue,  more  or 
less,  at  their  amusements. 

When  the  above  symptoms  have  continued  about  twenty-four  hours. 


29-i  VARICELLA. 

the  oru]it[on  appears  first  oxer_the_trnnk  and  soon  afterwards  over  tlie 
face  andjimbs.  It  consists  of  minute  di_sseaiiinated  papules,  -which  be- 
come \:esicular  in  the  course  of  a  fewJiours.  The  occurrence  of  the 
vesicular  stage  is  nearly  simultaneous  on  sill  parts  of  the  surface.  The 
vesicles  lack  the  hard  induratedBase  of  the  variolous  eruption,  though 
they  are  sometimes  surrounded  by  a  faint  zone  of  redness.  They  differ 
also  from  the  variolous  eruption  in  the  absence  of  umbilication,  and  in 
irreo-ularity  of  shape.  Some  are  small  and  acuminate,  some  hemispheri- 
cal, and  of  medium  size,  and  others  oval  or  elongated,  and  of  large  size. 
The  inflammation  is  quite  superficial,  not  involving  the  subcutaneous 
tissue,  and  scarcely  affecting  the  deepest  layer  of  the  skin. 

The  vesicles  vary  in  size  from  the  diameter  of  half  a  line  to  that  of 
even  three  lines.  They  occasionally  give  rise  to  slight  itching.  On 
the  second  day^of  the  eruption,  or  third  day  of  the  disease,  they  arc  stiTl 
fully  developed,  their  liquid  contents  being  nearly  transparent.  At  the 
close  of  this_day.the  liquid  begins  to  be  somewhat  ckuidy,  and  its  absorp- 
tioiT'commences.  On  the  fourth  day  of  the  disease_desi£cation  pro- 
gresses mpidly,  and  by  the  fifth  the  iicpiid  has  for  the  most  part  disap- 
peared, and  a  scab  results,  sinall,  thin,  and  of  a  yellowish-brown  color. 
The  scabs  are  soon  detached,  the  redness  which  indicated  their  seat 
disappears,  the  epiderm  which  had  been  raised  and  removed  by  the 
eruption  is  reproduced  in  its  normal  state,  and  in  a  few  days  all  evi- 
dence of  varicella  is  effaced.  A  cicatrix  occasionally  results,  but  it  is 
due  not  to  the  simple  varicellar  eruption,  but  to  a  sore  produced  from 
the  eruption  by  the  scratching  of  the  child. 

The  number  of  vesicles  varies  considerably  in  different  cases.  They 
are  never,  so  far  as  I  have  observed,  confluent ;  but  they  are  sometimes 
so  abundant  in  young  children,  that,  if  the  disease  were  variola,  it  would 
be  called  severe  discrete.  They  occur  also  on  the  buccal  and  faucial 
surfaces,  where  they  soon  break,  forming  small  ulcers. 
""UiAGNOSLS. — Obviously  the  only  diseases  with  which  varicella  is 
liable  to  be  confounded  are  such  as  present  vesicles  at  some  stage  of 
their  course.  From  the  local  vesicular  eruptions  this  disease  is  diag- 
nosticated by  the  fact  that  the  vesicles  appear  on  all  parts  of  the  sur- 
face. It  is  sometimes  mistaken  for  variola  or  varioloid,  or  vice  versa — 
a  mistake  very  damaging  to  the  reputation  of  the  physician.  The 
points  of  differential  diagnosis  are  the  symptoms  of  invasion — severe, 
and  lasting  three  or  four  days  in  the  one;  mild,  and  continuing  only 
one  day  in  the  other — an  era^on_j)iiiSsijag_jloEl^through  its  stages 
from  the  pajiulre,  to  the  pustular,  umbilicated,  with  circular,  raised,  and 
inflamed^  ba.se,  appearing  first  on  the  face  and  neck,  and  not  till  a  day 
later  on  tlie  legs,  in  the  one  disease  ;  while  in  the  other  the  evolution, 
shape,  and  course  of  the  eruption,  as  described  above,  are  materially 
different.  By  proper  attention  to  these  distinctive  features  it  is  rarely 
difficult  to  diagnosticate  the  two  diseases. 

The  PROGNOSIS  in  varicella  is  always  favorable.  It  does  not,  of  itself, 
endanger  life,  nor  seriously  incommode  the  patient ;  nor  does  it  give 
rise  to  complications  or  sequehc.  The  treatment,  therefore,  is  the 
simplest  possible.  Mild  diet,  ami  a  laxative,  may  be  prescribed  during 
the  febrile  period  ;  but  nothing  further  is  required. 


SECTION  III. 

NON-ERUPTIVE  CONTAGIOUS  DISEASES. 


CHAPTER    I. 

DIPHTHERIA. 

Diphtheria  is  a  disease  of  antiquity,  dating  back  at  least  as  far  as 
the  commencement  of  the  Christian  era.  Aret?eus,  at  the  close  of  the 
first  century  after  Christ,  described  the  Malum  iEgyptiacum  as  a 
malady  whicli  occurred  chiefly  among  children,  and  was  characterized 
by  a  Avhite  concretion,  spreading  over  the  tonsils,  a  fetid  breath,  and  in 
some  patients  by  a  return  of  food  through  the  nostrils,  and  by  great 
dyspnoea,  ending  in  suffocation.  Since  the  commencement  of  the  six- 
teenth century,  numerous  epidemics  of  it  have  been  observed  in  Europe 
and  America,  and  at  the  present  time  it  is  one  of  the  most  common  and 
fatal  epidemic  maladies  in  both  continents,  Avhile  in  many  localities, 
especially  in  large  cities,  it  is  established  as  an  endemic. 

Age. — Diphtheria  is  preeminently  a  disease  of  childhood,  a  large 
majority  of  the  cases  occurring  between  the  ages  of  two  and  ten  years. 
Under  the  age  of  one  y-ear  the  younger  the  child  the  less  the  liability 
to  it,  and  it  rarely  occurs  prior  to  the  fourth  month.  Tiie  age  of  the 
youngest  patient  in  my  practice,  so  far  as  I  recollect,  whose  disease  was 
undoubtedly  diphtheria,  was  three  months  and  a  few  days;  but  in  one 
instance,  I  observed  upon  the  fauces  of  an  infant  of  six  weeks,  whose 
brother  had  just  died  of  diplitheria,  a  few  white  specks,  like  grains  of 
salt,  over  each  tonsil,  which  disappeared  in  three  or  four  days,  without 
the  occurrence  of  any  marked  symi)tonis,  by  the  ap])licati()n  of  a  sohi- 
tion  of  chlorate  of  potassium.  Certain  physicians,  having  charge  of 
maternity  wards,  have  observed  a  disease,  occurring  in  newborn  infants, 
which  bears  some  resemblance  to  diphtheria,  but  wliich,  if  it  be  true 
diphtheria,  presents  anomalous  features.  Thus,  Dr.  W.  S.  Bigelow 
re])orts  in  the  Boat.  3fed.  and  jSar'/.  Joiirn.  for  March  11,  187-'),  ten 
cases,  occurring  between  Septeml)er  and  December,  1S7-],  in  tlio  Boston 
Lying-in  Asylum,  all  fatal  but  two.  The  prominent  symptoms  and 
anatomical  characters  were:  dark  hue  of  skin,  luicmaturia,  pseudo- 
membranous exudation  upon  certain  mucous  surfaces,  dark  green  stools, 
spleen  enlarged  and  dark,  kidneys  engorged,  and  in  sonie  of  the  cases 
efi'usion  of  bh)od  into  the  ]»clves  of  these  organs,  and  along  the  urinary 
tract,  ])rownish  casts  in  tlie  renal  tubes,  etc. 

Dr.  Bigelow  refers  to  what  aT)pears  to  have  been  similar  cases  in  one 

(U'JG; 


296  DIPHTHERIA. 

of  the  continental  asylums,  and  T  have  met  one  case  in  some  respects 
similar,  Avhich  I  saw  Avith  Dr.  Ewing,  of  New  York.  Malignant  diph- 
theria appeared  in  a^ family  in  West  Fifty-third  Street,  in  the  middle  of 
October,  1880.  The  patient,  a  boy  often  years,  died,  and  the  remain- 
ing two  children,  as  soon  as  the  nature  of  the  malady  was  ajjjiarent, 
Avere  sent  from  the  house.  Nevertheless,  one  of  these,  precisely  seven 
days  after  the  removal,  was  attacked  by  diphtheria  of  the  hemorrhagic 
form,  and  died  in  less  than  one  week.  Blood  escaped  from  the  nostrils, 
fauces,  under  the  skin  in  numerous  places,  causing  purpuric  spots,  and 
from  the  kidneys  or  urinary  tract,  causing  hajmaturia. 

The  mother,  Avho  Avas  at  this  time  in  the  sixth  month  of  pregnancy, 
continued  greatly  depressed  by  the  occurrence,  although  slie  was  robust, 
and  her  general  health  good.  She  had  been  in  constant  attendance 
upon  her  children.  Her  infant,  born  three  months  subsequently  to  the 
occurrence  of  diphtheria  in  her  family  (February  6,  1881),  Avas  Avell 
developed,  but  it  presented  a  similar  hemorrhagic  cachexia  to  that  in 
the  second  case  of  diphtheria.  Blood  escaped  from  the  vessels  under 
the  skin,  causing  blotches  and  prominences,  and  from  the  mucous  sur- 
faces. The  bleeding  Avas  especially  persistent  and  copious  from  the 
umbilicus,  so  that  death  occurred  in  less  than  a  week.  The  mother 
had  at  no  time  any  diphtheritic  symptoms,  yet  Ave  know  that  the  diph- 
theritic poison  is  subtle  and  penetrative,  producing  its  peculiar  inflam- 
mation upon  the  uterine  Avails  of  the  parturient  Avoman,  even  Avhen  her 
fauces  are  not  affected.  Nevertheless  the  etiological  relation  of  diph- 
theria to  cases  like  the  above  is  uncertain,  and  can  only  be  determined 
by  more  numerous  observations,  and  thorough  examination.  In  the 
epidemic  observed  by  Dr.  Bigelow,  so  far  as  appears  from  the  published 
account,  the  mothers,  and  other  inmates,  Avere  not  affected  Avith  diph- 
theria, and  this  must  give  rise  to  grave  doubt  Avliether  the  malady 
affecting  the  infants  Avere  really  diplitheritic.  Diphtheria  is  infrequent 
after  the  middle  period  of  life,  and  old  age  appears  to  possess  nearly  an 
immunity  from  it. 

Incubation. — It  is  only  in  exceptional  instances  that  Ave  are  enabled 
to  ascertain  the  incubative  period  of  diphtheria.  I  Avas  enabled  to  fix 
it  A'ery  nearly  in  the  folloAving  cases  Avhich  occurred  in  my  practice.  A 
boy  of  nine  years  Avas  in  the  same  room,  about  one  hour  on  Saturday, 
with  a  child  Avho  had  fatal  diphtheria.  On  the  following  Tuesday, 
without  any  other  exposure,  he  sickened  Avith  a  malignant  form  of  the 
same  disease.  Mrs.  E.  assisted  in  nursing  a  fatal  case  of  diphtheria, 
from  November  11  to  13,  1874,  after  Avhich  she  returned  home,  several 
blocks  aAvay.  On  the  evening  of  the  15th  she  complained  of  sore 
throat,  and  on  the  folloAving  day  the  diphtheritic  pseudo-membrane  Avas 
observed  over  her  tonsils.  On  the  19th  the  exudation  had  disappeared, 
and  she  Avas  convalescent.  On  the  20th  her  sister,  residing  Avith  her, 
and  Avho  had  not  been  elscAvhere  exposed,  was  similarly  affected,  and 
after  three  or  four  days  she  convalesced.  The  only  other  case  in  the 
family,  a  boy,  sickened  Avith  diplitheria  on  December  2.  In  the  first 
of  these  cases  the  incubative  period  seems  to  have  been  from  tAvo  to 
four  days  ;  Avhile  in  the  last,  it  Avas  apparently  longer.  In  April,  1876, 
a  little  girl  died  of  malignant  diphtheria  in  West  Forty-first  Street, 


NATURE.  297 

New  York  City.  Her  sister,  aged  one  year,  remained  with  her  from 
April  14  to  17,  when  she  Avas  removed  to  a  distant  part  of  the  city,  and 
phiced  in  a  family  where  there  Avas  no  sickness,  and  had  been  no  diph- 
theria. On  the  night  of  April  24,  seven  days  after  her  removal,  this 
infant  was  observed  to  be  feverish,  and  on  the  following  day,  when  I 
was  called  to  examine  her,  the  characteristic  diphtheritic  patch  had 
begun  to  form  over  the  left  tonsil.  In  April,  1875,  two  sisters,  aged 
s.even  and  five  years,  resided  with  their  parents,  in  a  boarding-house,  in 
West  Twenty-second  Street,  New  York.  A  playmate  in  the  same 
house  hud  symptoms  which  were  supposed  to  be  due  to  a  cold,  but  which 
were  diphtheritic,  when  one  night  severe  laryngitis  occurred,  and  ended 
fatally  the  same  day.  The  physician  who  had  been  summoned,  diag- 
nosticated diphtheria,  and  the  two  sisters  were  immediately  removed  to 
a  hotel.  But  seven  days  subsequently,  diphtheria  commenced  in  the 
older  child.  The  younger  was  then  removed  to  a  distant  part  of  the 
same  hotel,  but  on  the  sixth  or  seventh  day  subsequently  she  also 
became  affected  with  a  fatal  form  of  the  disease.  It  is  seen  that  the 
period  of  incubation  in  diphtheria,  like  that  in  scarlet  fever,  varies  in 
different  cases.  It  is  from  two  to  eight  days,  with  perhaps  an  occa- 
sional case  outside  these  limits. 

Nature. — Diphtheria  resembles  scarlet  fever  in  certain  particulars ; 
in  its  incubative  period,  as  we  have  seen  above,  in  its  variability  of  type 
from  a  very  mild  to  a  malignant  form,  in  the  common  seat  of  its  inflam- 
mations, namely,  upon  the  fauces  and  nasal  passages,  in  the  profound 
blood-poisoning  and  prostration  in  the  graver  cases,  and  in  the  frequent 
occurrence  of  nepliritis  as  a  complication  or  sequel.  It  resembles  both 
scarlet  fever  and  smallpox  in  the  fact  that  it  is  communical)le  both 
through  the  atmosphere  and  by  contact  or  inoculation.  It  resembles 
erysipelas  in  the  variableness  of  its  duration,  and  in  the  fact  that  one 
attack  does  not  protect  the  system  from  another.  In  its  etiology  it 
resembles  typhoid  fever,  for  it  is  not  only  communicable  from  person  to 
person,  but  it  is  produced  by  foid  exhalations,  as  sewer  gases.  But 
while  tliere  are  certain  resemblances,  it  is  distinguished  from  all  these 
infectious  diseases  by  marked  peculiarities. 

Diphtheria  is  primary  or  secondary.  The  secondary  form  most  fre- 
quently occurs  during  epidemics  of  the  other  infectious  diseases,  and  as 
a  complication  of  them.  Those  infectious  maladies  which  are  accompa- 
nied by  inlhunmation  of  the  fauces  and  air-passages,  are  most  lial)le  to 
this  coiupHcation  if  they  occur  in  a  locality  wliere  diphtheria  prevails; 
the  inflammations  of  the  mucous  surfaces  accompanying  them  being 
transformed  into  the  diphtheritic.  In  New  York,  scarlet  fever  beyond 
any  other  disease  appears  to  furnish  the  conditions  which  are  most 
favorable  for  the  occurrence  of  diphtheria,  and  if  these  maladies  bo 
epidemic  in  the  same  locality,  not  a  few  of  the  scarlatinous  patients  are 
ailected  witli  diphtheria  in  the  latter  ])art  of  the  first,  or  in  the  second 
week,  though  tlie  converse  seldom  haj)i)ens,  that  a  patient  with  dipli- 
theria  contracts  scarlet  fever.  The  other  infectious  diseases,  which  are 
most  lia])le  to  the  diphtheritic  com|)lication.  are  measles,  variola,  whoop- 
ing cough,  and  tyi»h()id  fever,  the  bronchitis  of  these  diseases  changing 
to  a  pseudo-membranous  inflammation. 


298  DIPHTHERIA. 

It  is  an  interesting  fact  that  in  a  patient  suffering  from  diphtheria, 
the  specific  infiammation  is  apt  to  occur  upon  such  surfaces  as  are  ah-eady 
the  seat  of  inflammation.  A  catarrhal  infiammation  however  produced 
is  liable,  under  the  influence  of  the  virus,  to  become  diphtheritic  and 
pseudo-membranous.  Thus,  if  I  recollect  correctly,  four  children  in  the 
New  York  Foundling  Asylum  have  had  diphtheritic  conjunctivitis, 
occurring  upon  trachoma,  and  Billroth  remarks  "  catarrhal  conjuncti- 
vitis, which  is  so  very  common,  may  become  diphtheritic"  [Sim/. 
JPathol.,  translated,  page  267).  All  who  have  seen  much  of  diplitheria 
are  familiar  with  instances  in  which  a  catarrhal  inflammation,  as  from  a 
burn,  blister,  or  wound,  as  from  tracheotomy,  becomes  dij)hthcritic. 
This  general  fact,  in  regard  to  the  nature  of  diphtheria,  and  its  mode  of 
manifestation,  namely,  that  in  one  afiected  by  diphtheria  the  di|)hthe- 
ritic  inflammations  appear  by  preference  upon  such  surfaces  as  are 
already  inflamed,  has  an  important  practical  bearing.  In  frequent 
instances  during  epidemics  of  diphtheria,  I  have  known  careful  and 
experienced  physicians  suppose  tliat  they  were  treating  catarrhal  inflam- 
mation of  the  air-passages,  Avhen  suddenly  indubitable  signs  of  diphthe- 
ritic disease  occurred,  usually  with  a  fatal  ending.  They  were  obliged 
to  confess  to  the  friends  of  the  patients  that  they  had  erred  in  diagnosis 
and  prognosis,  and  their  reputation  "\\  as  sometimes  seriously  compromised. 
Probably,  in  a  certain  proportion  of  such  cases,  there  was  a  change  of 
a  non-specific  catarrhal  to  a  di})htheritic  inflammation,  such  as  occurs 
in  scarlatinous  angina  or  rubeolous  laryngitis  in  those  who  contract 
diphtheria. 

The  frei|uent  occurrence  of  epidemics  of  diphtheria  during  the  last 
thirty  years,  and  the  great  mortality  Avhich  lias  attended  them,  have 
awakened  an  interest  in  this  malady  which  has  led  to  a  careful  study 
of  its  causes  and  nature.  Till  recently  these  inquiries  were  entirely 
clinical,  but  during  the  last  few  years  a  new  line  of  investigation  has  been 
followed,  namely,  that  of  experimenting  on  animals,  the  results  being 
observed  by  the  microscope;  and  while  it  has  led  to  the  confirmation  of 
facts  already  ascertained,  important  discoveries  have  been  made,  and 
more  important  ones  are  probal^ly  in  waiting.  Among  those  who  have 
taken  the  lead  in  this  new  field  of  investigation  are  Oertel,  Biihl,  and 
Hueter,  of  Germany.  These  microscopists,  and  several  other  experi- 
menters of  equal  reputation  who  uphold  their  vicAvs,  believe  that  they 
have  discovered  the  cause  of  diphtheria,  with  a  high  power  of  the  micro- 
scope, standing,  as  Oertel  says,  "on  the  very  borders  of  the  visible," 

Tbis  discovery  is  so  important,  not  only  in  itself,  but  from  the  promise 
which  it  gives  of  the  results  of  future  research,  and  from  tlie  stimulus 
which  it  iuiparts  to  such  in(purics,  that  a  brief  statement  of  tlie  facts  in 
reference  to  it  caimot  fail  to  be  interesting  at  the  present  time,  when 
diphtheria  is  so  prevalent  and  fital  in  this  city  and  country.  The  minute 
objects  which  the  observers  alluded  to  have  discovered  in  patients  affected 
with  diplitlieria,  and  which  they  suppose  cause  the  disease,  are  endued 
with  life  and  motion.  They  l^elong  to  the  class  of  microscopic  vegetable 
parasites  which  have  been  designated  haetei-ia.  The  bacteria  have  been 
divided  by  Cohn  into  four  genera,  with  species;  but  only  two  of  these, 
it  is  thought,  sustain  a  causal  relation  to  diphtheria,  namely,  the  sphere- 


NATURE  —  CAUSES.  299 

bacterium  or  spherical  bacterium,  or,  as  Oertel  designates  it,  the  micro- 
coccus; and  secondly,  though  in  less  degree,  because  less  numerous, 
tliough  coexisting  with  the  other  form,  and  penetrating  the  tissues  Avith 
it,  the  micro-hacterium,  or  rod-like  bacterium. 

The  microscope,  in  the  hands  of  various  observers,  has  revealed  the 
following  important  focts  relative  to  diphtheria:  In  every  tissue  Avhich 
is  the  seat  of  diphtheritic  inflammation,  and  in  every  diphtheritic  pseudo- 
membrane,  the  spherical  bacteria  occur  in  immense  numbers,  accom- 
panied by  a  smaller  number  of  the  other  kind.  In  severe  cases,  in  which 
the  system  is  infected,  they  occur  also  in  the  blood.  Ordinarily,  as  the 
symptoms  of  diphtheria  become  more  grave,  a  proportionate  increase  in 
the  number  of  spherical  bacteria  can  be  demonstrated  by  the  microscope. 
They  are  found  in  the  discharge  from  the  edges  of  the  wound  produced 
by  tracheotomy,  performed  in  the  treatment  of  diphtheritic  laryngitis, 
and  upon  these  edges  they  multiply  rapidly,  just  before  a  pseudo-mem- 
brane forms.  If,  upon  any  surface,  which  is  the  seat  of  ordinary  catar- 
rlial  inflammation,  other  vegetable  organisms,  as  the  leptothrix  buccalis, 
or  o'idium  albicans,  are  present — if  diphtheritic  inflammation  supervene, 
these  organisms  diminish  and  disappear,  as  if  deprived  of  the  required 
nutriment,  and  are  succeeded  by  the  sphero-  and  micro^bacteria,  Avhicli 
increase  in  numbers  as  the  specific  inflammation  extends.  On  the  other 
hand,  when  the  diphtheritic  inflammation  abates,  these  bacteria  disap- 
pear, and  other  vegetable  forms  may  succeed.  In  the  very  commence- 
ment of  diphtheria,  the  grayish-white  spots  which  appear  upon  the  inflamed 
surface  consist  entirely  of  these  bacteria,  with  epithelial  cells  and  mucus, 
while  fibrin  and  pus  appear  at  a  later  period,  as  a  result  of  inflammatory 
reaction. 

These  facts  having  been  ascertained,  various  experiments  were  made 
by  Oertel,  Ilueter,  Von  Trendelenburg,  Nasseloff",  Eberth,  and  others, 
in  order  to  determine  more  fully  the  exact  relation  of  the  sphero-bac- 
teria  and  micro-bacteria  to  diphtheria.  These  organisms  were  not  found 
in  the  croupous  membrane  produced  by  tlie  applicaticm  of  a  ])owerful 
chemical  iigcnt,  as  ammonia,  nor  U))on  the  inflamed  surface  underneath 
the  membi-ane,  "although  the  fibrous  exudation  aftbrded  a  soil  which 
varied  little  or  not  at  all  in  its  histological  and  chemical  composition 
from  that  induced  by  diphtheria."  (Oertel.)  The  mucous  membrane 
of  the  air-passages,  the  cornea  and  muscles  in  animals,  were  inoculated 
with  diphtheritic  matter,  and  these  two  kinds  of  bacteria  were  found  to 
increase  rapidly,  penetrating  the  tissues  in  a  short  time,  and  infecting 
the  system.  Oertel  says:  "I  have  noticeil  in  numerous  inoculations 
that  if  various  bacteria,  besides  the  micrococcus,  as,  for  instance,  bacil- 
lus, s))irillum,  and  bacterium  lineola,  were  present  in  the  matter  to  be 
inoculated,  only  micrococci  (sphcro-bactcria)  and  the  bacterium  termo 
(in  its  most  minute  forms  accoinj)anyiiig  them)  showed  evidence  of  })ro- 
lific  growth,  while  all  other  forms  disap])eared  altogether."  Nasseloff 
and  Eberth  inoculated  the  cornea  with  dii)htheritic  niiittcr,  and  found 
that  the  sphero-bacteria  and  micro-bacteria  ])enetrated  its  layers,  forcing 
them  apart,  and  causing  within  a  few  days  intense  keratitis  and  the 
death  of  the  animal  by  infection  of  the  blood.  "In  the  same  way," 
says  Oertel,  "  according  to  my  experiments,  the  bacteria  spread  over 


300  DIPHTHERIA. 

the  mucous  membrane  of  the  tracliea,  beset  the  celhilar  elements,  crowd 
especially  into  the  young  exudation  cells,  or  are  taken  up  by  them,  and 
gradually  cause  their  dissolution  ;  they  fill  the  blood  and  lymph-vossels, 
and  bring  about,  in  a  mechanical  way,  a  damming-up  of  the  fluids,  and, 
as  a  consequence,  serous  exudation.  As  they  close  up  the  capillary 
vessels,  they  occasion  stagnation  in  the  blood  circulation,  which  induces 
disturbance  of  nutrition  in  the  walls  of  the  capillaries,  and  even  rup- 
ture of  the  same.  Muscular  fibres,  also,  which  are  covered  and  filled 
with  colonies  of  micrococci,  degenerate  and  slough ;  in  like  manner,  in 
severe  cases,  immense  numbers  of  bacteria  appear  heaped  up  in  the 
uriniferous  tubules  and  Malpighian  corpuscles  of  the  kidneys,  and  occa- 
sion there  parencliymatous  intlammation,  capillary  embolism  of  the  glo- 
meruli of  the  kidney,  with  ru])tured  vessels  and  formation  of  epithelial 
casts  in  the  tubes.  In  the  lymph  and  blood  streams  (compare  also 
Hueter),  in  long-continued  sickness  of  the  animal  experimented  on, 
these  bacteria  also  accumulate  in  masses.  They  induce,  as  exciters  of 
decomposition  and  disorganization  of  organic  nitrogenous  bodies,  septi- 
caemia, through  the  vegetative  process  they  undergo,  and  through  their 
relation  to  oxygen." 

Finally,  Erfurth  repeatedly  inoculated  the  cornea  with  a  negative 
result,  using  for  the  purpose  diphtheritic  material  from  which  the  bac- 
teria had  been  so  far  as  possible  separated. 

The  importance  of  such  experiments  cannot  be  too  highly  estimated. 
In  the  opinion  of  those  who  have  performed  them,  the  conclusion  is 
certain  that  diphtheria  is  produced  by  bacteria,  which,  coming  in 
contact  with  the  mucous  membrane,  or  the  cuticle  deprived  of  its  epi- 
dermic covering,  adhere  to  it ;  and  these,  multiplying  rapidly,  burrow 
through  the  tissues,  and  entering  the  vessels,  infect  the  whole  system. 
The  reason  assigned  why  diphtheritic  inflammation  in  most  cases  appears 
primarily  and  chiefly  upon  the  faucial  and  nasal  surfaces  is,  that  the 
air,  which  contains  the  germs  of  the  bacteria,  constantly  passes  over 
these  surfaces,  and,  as  regards  the  fauces,  the  ingesta  also,  which  may 
contain  them. 

But  the  causes  and  nature  of  a  disease  cannot,  in  general,  be  fully 
elucidated  by  experiments  alone,  such  as  have  been  detailed.  They 
should  be  aided  or  supplemented  by  clinical  observations,  and  of  these, 
as  regards  diphtheria,  we  have  had  an  abundance  in  New  York  during 
the  past  fifteen  years.  Clinical  observations  may  modify  or  correct  the 
theories  derived  from  the  results  of  experiments. 

But,  notwithstanding  the  many  experiments  and  observations  which 
have  been  made,  the  etiology  of  di))htheria,  as  Ziegler  remarks,  is  still 
in  doubt,  though  it  is  highly  probable  that  its  specific  principle  is  the 
microorganism  mentioned  above,  "which  "  settles  in  the  tissues  "  where 
the  specific  inflammation  occurs,  and  thence  "spreads  through  the 
system"  (Ziegler).  Wood  and  Formad,  who  in  the  employment  of 
the  State  Board  of  Health  made  many  experiments  in  1882,  arrived 
at  the  conclusion  that  micrococci  are  always  present  in  diphtheria,  but 
they  express  the  opinion  that  they  are  the  ordinary  sluggish  micrococci 
which  are  endued  with  "  new  power  and  virulence,"  and  that  they  are 
the  specific  principle  of  diphtheria. 


NATURE  —  CAUSES.  301 

The  question  whether  diphtheria  is,  in  its  inception,  a  kical  or  a 
constitutional  disease  has  been  much  discussed.  If  we  accept  the  plausi- 
ble opinion  that  the  virus  gains  admission  into  the  system  by  lodgement 
upon  one  of  the  exposed  surfaces,  still  clinical  facts  justify  the  belief 
tliat  it  quickly  enters  the  system  by  the  lymphatics  or  bloodvessels,  so 
that  the  judicious  physician  will  make  use  of  constitutional  measures 
from  the  commencement  of  his  attendance.  It  is  proper  to  state  that 
AVood  and  Formad  did  not  find  micrococci  in  the  blood  in  the  mildest 
cases,  but  in  cases  of  ordinary  severity  they  were  always  present,  so 
that,  in  their  opinion,  the  mildest  diphtheria  may  remain  a  local  malady ; 
but  it  seems  to  me  that  the  following  facts  justify  the  belief  that,  as  it 
ordinarily  occurs,  dijihtheria  should  be  regarded  and  treated  as  a  con- 
stitutional malady  from  the  first  visit  of  the  physician.  If  the  mildest 
cases  remain  local,  still  all  such  cases  as  involve  danger  are  or  quickly 
become  constitutional : 

1.  It  is  a  law  in  pathology  that  those  diseases  which  have  or  may 
have  a  long  incubative  period — say  of  a  week  or  more — are  constitu- 
tional. 

2.  Another  fact,  which  indicates  primary  blood-poisoning  in  diph- 
theria, is  observed  in  certain  cases,  namely,  the  occurrence  of  severe 
constitutional  symptoms  for  a  longer  or  shorter  time,  perhaps  for  half 
a  day,  before  the  appearance  of  the  usual  inflammation.  Thus  a  girl 
of  five  years,  having  malignant  diphtheria,  Avhom  I  saw  in  consultation, 
was  carefully  examined  on  the  first  day  of  her  sickness  by  the  attending 
physician,  and,  although  he  closely  inspected  the  fauces,  there  was  no 
appearance  Avhich  indicated  the  nature  of  the  malady  till  the  subsequent 
day.  In  such  cases,  a  sufficient  niun])er  of  which  I  have  observed, 
there  is  apt  to  be  complaint  of  soreness  of  the  throat,  or  difficulty  in 
swallowing,  almost  from  the  beginning  of  the  general  symptoms;  but 
the  pain  and  tenderness  seem  to  be  in  the  deeper  tissues  of  the  neck. 

Again,  treatment  of  the  inflammations  by  the  most  reliable  and  effi- 
cient antiseptics  and  disinfectants  wliich  wo  possess,  commenced  at  the 
earliest  possible  moment  and  repeated  at  short  intervals,  does  not  pre- 
vent the  occurrence  of  indubitable  symptoms  of  blood-poisoning  in  cases 
of  a  severe  type.  Thus  I  have  treated  every  portion  of  the  inflamed 
surface,  so  far  as  it  was  accessible,  every  second  or  third  hour,  with 
carbolic  acid  and  other  disinfectants,  almost  from  the  very  connnence- 
mcnt  of  diphtheria,  and  so  thoroughly  that  any  vegetable  or  animal 
poison  with  wliich  the  remedies  had  come  in  contact  would  probably 
have  been  destroyed,  or  rendered  inert,  and  yet,  except  in  mihl  cases, 
symptoms  of  diphtheritic  blood-poisoning  have  occurre<l,  and  as  early 
and  uniformly  as  if  less  energetic  local  measures  had  been  employed. 
While,  therefore,  I  do  not  fail  to  recommend  local  treatment  as  calculated 
to  diminish  septic  poisoning,  and  relieve  the  inflammations,  T  have  lost 
confidence  in  it  as  a  means  of  preventing  the  entrance  of  the  dii)htheritic 
poison  into  the  blood.  Its  powerlessness  to  prevent  contnmination  of 
the  blood  by  the  diphtheritic  virus  is  an  additional  evidence  that  this 
contamination  occurs  early. 

3.  The  quick  succumbim)  of  the  system  in  certain  malijinant  cases  is 
evidently  due  to  diphtheritic  toxaimia.     We  sometimes  observe  a  fatal 


302  DIPHTHERIA. 

result  on  the  second,  tliinl,  or  fourth  day,  without  any  dyspnoea,  or 
sufficient  laryngitis  to  compromise  life.  Cases  of  this  kind,  terminating 
fatally  even  in  the  first  day,  have  been  reported.  The  system  is  suddenly 
overpowered  by  the  poison,  struck  down,  as  it  were,  by  the  profound 
blood  change,  while  the  inflammations  are  still  in  their  incipiency. 

4.  Important  evidence  of  the  constitutional  nature  of  diphtheria  is 
afforded  also  by  the  state  of  tin'  kidneys.  No  internal  organs  are  so  often 
affected  in  diphtheria  as  the  kidneys,  and  on  account  of  their  location 
and  anatomical  relation,  it  is  evident  that  the  poison  first  passes  through 
the  system  before  it  reaches  them.  Any  clinical  or  anatomical  fact, 
therefore,  which  indicates  that  the  diphtheritic  virus  has  reached  and 
affected  the  kidneys,  affords  proof  that  it  has  penetrated  the  system, 
and  poisoned  the  blood.  Now  the  occurrence  of  albumen,  with  granular 
or  hyaline  casts,  in  the  urine,  in  cases  unattended  by  dys])noea,  affords 
proof  of  nephritis,  caused  by  the  action  of  the  poison  on  the  kidneys. 

Sir  John  Rose  Cormack,  of  Paris,  in  a  series  of  interesting  and 
useful  papers  relating  to  diphtheria,  published  in  the  Edinburgh  Medical 
Journal  during  1876,  states  that  albuminuria,  and  of  course  the 
nephritis  on  which  it  depends,  sometimes  begin  as  early  as  the  first 
day.     My  observations  confirm  this  statement,  as  in  the  following  cases: 

Case  1. — L.  McD.,  aged  three  years,  was  first  visited  by  me  on  February 
29,  1870.  I  learned  from  the  parents  that  she  had  been  feverish  during 
the  preceiling  forty-eight  hours,  and  her  urine  very  scanty.  A  moment's 
examination  was  sufficient  to  show  that  the  case  was  one  of  malignant 
diphtheria,  for  the  fauces  were  alieady  nearly  covered  by  the  diphtheritic 
pellicle,  the  temperature  was  lU.jj°,  and  the  pulse  140.  The  skin  was 
\\0o  and  dry,  and  there  was  moderate  swelling  under  the  ears,  and  a 
muco-purulent  discharge  from  the  nostrils.  On  account  of  the  scantiness 
of  the  urine,  the  amount  not  exceeding  fsiv-v  daily,  it  was  impossible  to 
obtain  sufficient  for  examination  till  the  following  day.  It  was  tlien 
f  )und  to  have  a  specific  gravity  of  10.'>2,  to  contain  a  deposit  of  urates 
and  hyaline  and  granular  casts,  a  diminished  amount  of  urea,  and  a  large 
quantity  of  albumen.  It  can  hardly  be  doubted,  from  the  scantiness  of 
the  urine,  and  the  large  amount  of  albumen  found  when  the  urine  was 
first  examined,  that  albuminuria  had  been  ])resent  on  the  first  day. 

Case  2. — The  following  was  a  similar  ciise:  K.,  aged  four  years,  living 
in  West  Thirty-sixth  Street,  was  visited  by  me  in  consultation  on  Jan. 
29,  1875.  Her  sickness  had  also  continued  forty-ei2:ht  hours  ;  her  fauces 
Avere  swollen,  and  cov^ei'ed  with  the  diphtheritic  pellicle,  which  was  dark 
and  offensive;  respiration  guttural;  pulse  120;  temp.  101°;  she  had  a 
free  discharge  from  each  nostril;  urine  scanty,  its  specific  gravity  1030; 
it  contained  a  small  amount  of  albumen,  with  casts,  and  a  large  amount 
of  urates,  with  no  apparent  diminution  of  the  urea.  Death  occurred  on 
the  fourth  day, 

,  In  such  severe  cases,  in  which  albumen  and  casts  are  found  in  the 
urine  at  the  first  visit  of  the  physician,  there  can  be  little  doubt  that 
the  nephritis  begins  nearly  or  quite  as  early  as  the  pharyngitis,  and 
therefore,  since  poisoning  of  the  blood  must  antedate  the  renal  disease, 
diphtheria  affects  the  system  very  early,  probably  from  the  occurrence 
of  the  first  symptoms. 


NATURE  —  CAUSES.  303 

Again  there  are  cases,  though  not  frequent — three  I  can  recall  to 
mind  during  the  last  two  years  in  my  practice — in  which  the  external 
manifestations  of  diphtheria  are  veiy  mild,  even  insignificant,  and 
quickly  cured,  but  in  which  the  kidneys  are  early  and  severely  aflfected. 
The  occurrence  of  such  cases  is  best  explained  on  the  supposition  of 
an  early  and  profound  blood  change.  The  following  are  histories  of  the 
cases  alluded  to : 

The  house  229  West  Nineteenth  Street,  Xew  York,  is  an  old  wooden 
structure,  and  the  family,  which  lias  occupied  it  during  the  last  five  years, 
has  been  three  times  visited  by  diphtheria,  the  first  case,  that  of  the  oldest 
child,  proving  fatal.  In  February,  1876,  one  of  the  children  had  diph- 
theria in  a  moderately  severe  form.  He  recovered,  and,  after  my  visits 
had  been  discontinued,  his  sister,  aged  six  years,  who  had  had  scarlet  fever 
when  eighteen  mouths  old,  became  feverish,  and  complained  of  her  throat. 
No  rash  appeared  on  her  skin,  and  there  was  apparently  no  coryza.  In- 
spection of  the  fauces  by  the  parents  revealed  a  suiall  diphtheritic  patch 
over  each  tonsil.  Although  diphtheria  was  so  frightful  a  malady  to  this 
family  from  their  past  experience,  the  case  seemecl  so  mild  that  the  parents 
treated  it  without  medical  attendance,  by  the  remedies  which  had  been 
employed  fir  the  boy.  A  mixture  of  carbolic  acid,  subsulphate  of  iron, 
and  glycerine,  was  applied  to  the  fauces  every  third  hour,  sufficiently 
often,  apparently,  to  destroy  all  bacteria  or  other  vegetable  or  animal 
organisms  with  which  it  might  have  come  in  contact,  and  within  two  or 
three  days  the  inflammation  of  the  throat  seemed  to  the  parents  to  be 
cured.  Nevertheless,  with  this  insignificant  inflammation  of  the  fauces, 
s )  quickly  subdued,  and  with  no  other  apparent  inflammation  of  the 
mucous  surfaces,  there  was  severe  internal  disease  going  on  as  the  result 
of  the  general  infection.  The  child  did  not  regain  her  former  appetite ; 
she  had  increasing  pallor,  although  able  to  ])lay  about  the  house  :  and, 
finally,  in  the  third  week,  when  I  was  called  to  see  her,  slight  (edenia  of 
the  face  and  limbs  was  observed.  Her  urine,  which  was  scanty,  was  found 
to  contain  pus  and  blo)d  c  )rpusele;s,  albumen,  and  granular  casts,  and 
nearly  two  months  elaps3d  bof  )re,  under  treatment,  it  became  normal, 
and  her  health  was  restored. 

The  sec  )nd  case  occurred  in  January,  l-'Sj-S,  in  West  Fifty-first  Street. 
A  boy,  aged  six  years,  in  a  faini'y  in  which  diphtheria  was  occurrin^r,  had 
HJight  sore  throat,  which  abated  in  two  or  three  days.  It  was  attended  by 
little  or  no  exudation,  and  would  not  have  been  considered  diphtheritic, 
except  for  the  circumstances  in  which  it  occurred,  and  the  subsequent 
history.  Still,  the  boy  remained  ill,  and  fretful,  and  four  days  sub.se- 
quently  his  urine  was  found  to  be  very  scanty  and  very  albuminous;  and 
three  days  later  death  occurred,  preceded  by  total  suppression  of  urine. 
The  last  urine  passed,  which  was  not  more  than  a  teaspooni'ul,  became 
nearly  semi-.solid  by  heat.     There  had  been  no  scarlet  fever  in  the  family. 

Cases  like  the  above,  in  which  there  is  an  early  and  profound  systemic 
infection,  with  but  slight  evidence  of  lodgement  of  the  virus  upon  the 
faucial  or  other  exposed  surface,  are  interesting  as  showing  the  consti- 
tutional nature  of  the  malady,  even  when  the  symptoms  and  visible 
lesions  have  extreme  mildness. 

Diplitheria,  as  experiments  on  animals  and  the  histories  of  many 
reported  cases  show,  is  sometimes  communicated  by  inoculation.     Most 


304  DIPHTHERIA. 

frequently,  lioAvcver,  tlie  virus  is  received  from  an  infected  atmosphere. 
The  antihygienic  conditions  in  which  it  originates  arc  ■well  known. 
Many  cases  in  New  York  are  traced  to  sewer  gases,  which  have  escaped 
into  houses  through  imperfect  plumbing. 

"Wlien  diphtheria  reappeared  in  New  York  in  1858,  after  an  absence 
of  more  than  fifty  years,  some  of  the  first  and  most  severe  cases  seen 
by  m3'self  occurred  in  the  upper  part  of  the  city,  along  the  old  water- 
courses, wliere,  in  conserpience  of  street  grading,  water  was  stagnant 
and  impregnated  with  decaying  animal  and  vegetable  matter.  Though 
observing  and  treating  diphtheria,  both  in  its  epidemic  and  sporadic 
form,  during  the  last  twenty-five  years,  I  have  not  observed  an  instance 
in  which  it  seemed  to  be  communicated  from  house  to  house  by  the 
clothing  of  a  third  person,  as  we  frequently  observe  in  cases  of  scarlet 
fever,  and  sometimes  of  measles.  When  it  spreads  from  house  to  house, 
or  even  from  room  to  room,  in  the  same  house,  1  think  that  it  is  almost 
always  by  the  visits  of  persons  having  diphtheritic  inflammation.  The 
area  of  contagiousness  of  diphtheria  is  therefore  limited  to  the  room  in 
which  the  patient  resides,  or  to  his  immediate  vicinity. 

But  it  is  well  known  that  the  sputum  of  a  diphtheritic  patient  and 
bits  of  diphtheritic  pseudo-membrane  may  communicate  di])htheria. 
Experiments  indeed  show  this,  as  do  many  observations  published  in 
the  records  of  diphtheria.  Therefore,  caution  is  required  that  children 
be  not  needlessly  exposed  to  the  handkerchiefs  or  towels  employed  by 
a  patient,  nor  to  his  breath,  especially  during  the  act  of  coughing. 
We  may  here  repeat  that  in  localities  Avhere  diphtheria  is  endemic  or 
epidemic,  certain  constitutional  diseases  sustain  a  causative  relation  to 
diphtheria.  Thus  scarlet  fever  furnishes  the  conditions  in  which  diph- 
theria arises  in  a  house  whose  sanitary  state  is  apparently  good,  and 
when  there  has  apparently  been  no  expOvSure  to  a  diphtheritic  patient. 
In  three  instances  I  have  known  diphtheria  thus  originating  to  become 
dissociated  from  scarlet  fever,  and  spread  as  a  primary  and  independent 
malad}'. 

Anatomical  Characters. — In  the  commencement  of  diphtheria 
we  observe  redness  of  some  portion  of  the  mucous  surface.  In  most 
cases  it  is  the  fauciaLmembrane  which  is  fixat  affected,  and  that  part  of 
it  which  covers  the  tonsils.  If  there  be  a  preexisting  inflammation  of 
one  of  the  other  mucous  surfaces,  or  a  portion  of  tlio  cuticle  denuded 
of  its  epidermis  and  inflamed,  the  specific  inflammation  is  apt  to  appear 
primarily  upon  these  parts,  with  or  without  its  simultaneous  appearance 
upon  the  faucial  surface,  a  fact  to  which  allusion  has  been  made  above. 

The  inflammation  varies  greatly  in  severity  and  extent.  In  a  mild 
attack  it  is  often  limited  to  a  part  of  the  fauc^,  and  there  arc  few 
exceptions  to  the  rule  that  the  tonsillar  portion  is  affected,  the  redness 
gradually  fa^ding  away  in  the  healthy  membrane  beyond.  In  all  except 
the  mildest  cases,  the  whole  faucial  surface  is,  in  the  course  of  a  few 
hours,  involved  in  the  inflammatory  process,  its  mucous_inembrane  is 
thickened  and  softened,  and  its  foliicle_s_tumefied,  and  actiyelj  secret- 
ing.  In  .5eyere  cases  the  uvula  is  elongated  and  enlOirged  from  Avatery 
infiltration ;  the  submucous  connective  tissue  also  becomes  involved  to 
a  greater  or  less  extent,  and  swells ;    and    the  submucous  lymphatic 


AXATOMICAL    CHARACTERS.  305 

glands,  especially  the  tonsils,  also  sjvell,  and  are  painful.  The  color 
of  the  inflamed  surfiice  is  sometimes  a  deep,  bright  red,  almost  like 
arterial  blood ;  in  other  cases  it  is  a  dusky  re_d,  which  indicates  a  viti- 
ateTTstate  of  the  blood.  The  dusky  red  hue  is  more  common  in  second- 
ary than  in  primary  diphtheria ;  it  is  also  common  in  the  obstructive 
laryngitis  of  diphtheria,  the  color  becoming  more  and  more  dusky  as 
the  obstruction  increases. 

Within  a  day,  and  usually  within  a  few  liours,  from  the  commence- 
ment of  the  inflammation,  a  small  slightlyj^iised  patch  or  sj30t  is  ob- 
served, u-ually  upon  the  tonsilTar  portTou  of  the  inflamed  surface,  of 
little  importance,  did  the  disease  stop  here,  but  very  significant  as  a 
diagnostic  sign,  and  as  a  forerunner  of  what  is  to  happen.  This  patch, 
termed  the  pseudo-membrane,  gradually  becoiiies^  firmer,  and  at  the 
same  time  thicker  and  broader  from  fresh  exudations  underneath,  and 
it  ha^  a  grayish  or  grayijh^white  color.  Sometimes  different  points  or 
patches  areoBserved,  which  extend  and  coalesce  so  that  the  fauces  are 
almost  entirely  concealed  from  view.  The  p!>eudo-membrane  is  closely 
attached  to  tlie  mucous  surface,  which  it  pgnetrateg,  becoming  firm,  and 
noFeasTly  detaclied.  Attempts  to  separate  it  often  lacerate  the  engorged 
capillaries,  producing  a  free  flow  of  blood.  It  does  not  ordinarily  attain 
a  greater  thickness  than  ojie-eighth  to  one-sixth  of  .an  inch.  I  have 
seo'n  it,  however,  not  far  from  one-third  of  an  inch  thick.  By  the 
microscope  we  observe  numerous  micrococci  with  a  small  number  of 
roddike  bacteria  in  the  meshes  of  the  exudation.  They  can  be  traced 
through  the  subepitlielial  tissues,  being  adherent  to  and  even  incorpo- 
rated in  pus-cells,  and  entering  into  and  blocking  up  the  minute  lym- 
pliatics  and  bloodvessels. 

The  same  pseudo-membrane  is  often  firmer  in  one  part  than  another, 
tlie  outer  and  central  portions  being  more  compact  and  tough  for  a  time 
than  tliat  underneath,  ^vhich  is  more  recent,  and  in  which  there  is  less 
fibrillation.  After  a  few  days,  however,  decomposition  commences,  and 
then  that  Avhich  was  tii^st  tormed  becomes  softer  than  the  more  recent 
production.  When  this  occurs,  the  color  of  the  exudation  cluin;^es  from 
a  whitish  or  a  grayish-white  to  a  dirtvTSrow-ii,  and  its  exposed  surface  is 
uneven  and  jagged  from  the  partial  separation  of  shreds  and  fibres. 

The  escape'of~the  liquor  sanguinis  from  the  engorged  vessels  dimin- 
ishes somewhat  the  turgesccnce  of  the  inflamed  tissue.  If  this  be  con- 
siderable, the  pseudo-membrane  often  sinks  to  the  level  of  the  .surround- 
ing surface,  producing  an  appearance  very  much  like  that  of  an  ulcer, 
or  even  of  gangrene.  Though  there  is  no  loss  of  substance  in  this  stage 
of  the  pseudo-meml)rane,  it  does,  however,  often  occur,  1>cing  produced 
by  the  presence  and  contraction  of  the  fibrin  with  which  the  mucous 
membrane  is  infiltrate<l.  Sometimes  the  pseudo-membrane  has  a  red- 
dish tinge.  This  is  due  to  rupture  of  the  capillaries,  and  the  escape  of 
the  blood-corpuscles.  It  occurs  in  those  cases  in  which  the  inllamma- 
tion  is  intense,  ami  the  capillaries  are  greatly  engorged.  Sometimes 
the  lower  part  of  the  exudation  is  blood-stained,  wliile  the  exposed  sur- 
face has  the  usual  grayish-white  hue. 

Briefly  stated,  the  exudatjon  of  diphtheria  is  fjjijnd  to  consist  of 
fibrin  forming  a  delicatiTTntcrlacing  network,  ejiithelial  cells  more  or 
""  20      "^"^      '"         '~~ 


306  DIPHTHERIA. 

less  altered  by  the  inflammatory  process,  leucocytes,  nuclei,  mucus,  and 
amorphous  matter.  Upon  the  faucial,  buccal,  laryngeal,  anTT^^erhaps 
also  nasal  surfoces,  the  pseudo-menibrane"penctrates  the  entire  mucous 
membrane,  so  that  no  line  of  demarcation  between  them  can  be  seen 
with  the  microscope.''T5elo'\vtrie~lal"ynx  upon  the  surface  of  the  trachea 
and  bronchial  tubes,  a  distinct  line  of  demarcation  exists,  as  in  the 
croupous  exudation,  so  that  the  tracheal  and  bronchial  pseudo-membrane 
can  be  readily  detached,  without  impairing  the  integrity  of  the  under- 
lying mucous  surface. 

The  inflamed  mucous  membrane  is  not  only  hyperremic  and  infil- 
trated Avith  serum,  but  it  contains  numerous  round  white  corpuscles 
(leucocytes),  which  may  result  in  part  from  proliferation  of  connective 
tissue  corpuscles,  but  are  believed  by  most  pathologists,  since  Cohn- 
heim's  well-known  discovery,  to  be  in  great  part  wandering  white  cor- 
puscles of  the  blood,  which  have  escaped  through  the  walls  of  the 
bloodvessels  along  with  the  fibrin.  In  the  commencement  of  the  diph- 
theritic inflammation,  before  the  pseudo-membrane~ionns,  we  often 
observe  a  grayisli_ tinge  of  the  mucous  surface,  which  is  due  to  the 
crowding  of  these  cellular  elements  underneath  and  in  the  mucous 
memln-ane,  for  these  newly  formed  cells  can  be  traced  into  the  sub- 
mucous connective  tissue.  Even  Avhere  the  .inflammation  remains 
catarrhal,  as  it  does  over  certain  areas  in  all  cases  of  diphtheria,  this 
infiltration  of  the  mucous  and  submucous  tissues  with  cells  is  common. 

During  the  height  of  the  inflammation,  it  is  astonishing  often  to  see 
with  what  rapidity  the  pseudo-membrane  returns,  when  removed  by 
force.  A  few  hours  suffice  to  restore  it  as  firm  and  extensive  as  before 
the  interference.  In  favorable  cases  this  adventitious  layer  is  detached 
in  a  few  days,  and  is  either  expectorated  or  swallowed  with  the  ingesta. 
Its  separation  is  promoted  by  the  secretions  underneath,  especially  by 
pus,  which  is  formed  in  abundance  between  it  and  the  surface  on  which, 
and  in  which  it  lies.  In  most  cases  it  does  not  separate  in  mass,  but 
disapi^ears,  by  progressive  liquefaction,  a  little  less  remaining  at  each 
visit  till  all  is  detached. 

Such  are  the  appearances,  character,  and  history  of  the  pseudo-mem- 
brane in  this  malady.  Although  its  common  seat  is  upon  the  fauces, 
and  in  mild  cases  it  occurs  only  upon  the  fauces,  nevertheless  all  the 
mucous  surfaces  ai'e  liable  to  be  attacked  by  the  inflammation,  in  conse- 
quence of  mfection  of  the  blood,  and  therefore  in  severe  cases,  and  even 
in  cases  of  moderate  severity,  we  often  find  the  product  elsewhere,  as 
well  as  upon  the  fauces,  and  in  localities  where  from  its  mechanical 
effect  it  greatly  increases  the  danger  and  even  compromises  life.  The 
mucous  membrane  of  the  nostrils,  mouth,  larynx,  trachea,  bronchial 
tubes,  oesophagus,  stomach,  intestines,  conjunctiva,  vagina,  and  even  the 
delicate  lining  of  the  middle  ear,  arc  at  times  the  seat  of  diphtheritic 
inflammation,  with  the  cliaracteristic  product.  In  a  case  which  oc- 
curred in  the  Nursery  and  Child's  Hospital  of  New  York,  the  surface 
of  the  stomach  was  almost  completely  lined  with  the  diphtheritic  forma- 
tion, so  that  the  function  of  this  organ  was  apparently  nearly  or  quite 
abolished.  The  occurrence  of  the  pseudo-membrane  in  the  nares  is 
common,  and  is  attended  by  the  dischai'ge  of  thin  mucus  and  pus,  but 


ANATOMICAL    CHARACTERS  307 

though  inconvenient  to  the  patient,  its  mechanical  effect  is  not  dan- 
gerous, except  in  the  nursing  infant,  in  Avhom  it  interferes,  more  or 
less,  with  lactation.  The  thin  irritating  discharge  produces  excoriation 
around  the  nostrils,  and  upon  the  u£perjip.  I  have  met  only  onF case 
of  diphtheritic  inflammation  of  the  intestines,  in  which  the  diagnosis 
was  certain.  A  physician,  in  whose  family  severe  diphtheria  had  just 
occurred,  took  what  was  believed  to  be  typhoid  fever.  After  a  long 
sickness,  he  expelled,  per  rectum,  about  one  foot  of  diphtheritic  pseudo- 
membrane  in  a  cylindrical  form,  evidently  produced  upon  the  intestinal 
walls.  In  the  subsequent  months  the  patient  suffered  from  constipation, 
and  severe  abdominal  pains,  apparently  due  to  contraction  in  healing 
of  the  large  diphtheritic  intestinal  ulcer.  Death  finally  occurred  from 
this  state  of  the  intestines.  The  formation  of  the  diphtheritic  pellicle 
upon  the  vulva  and  vaginal  walls  is  occasionally  observed,  as  in  one  of 
the  cases  related  above.  Its  occurrence  upon  the  uterine  surface  is 
very  rare,  except  in  the  parturient  woman,  in  whom  it  is  said  to  occur 
by  preference  upon  that  part  from  which  the  pkicenta  has  been  detached. 

In  mild  cases  of  diphtheria,  in  which  the  pseudo-membrane  is  small, 
and  (juite  superficial,  penetrating  but  little  the  mucous  membrane,  in 
which  it  is  embedded,  there  is  little  danger  of  septic  poisoning.  But  in 
grave  cases,  in  which  the  diphtheritic  pellicle  is  extensive,  and  deeply 
embedded,  so  that  the  lymphatic  and  bloodvessels  are  in  immediate 
relation  with  its  under  surface,  the  conditions  in  which  septicaemia 
occurs  are  present  as  soon  as  decomposition  begins.  Therefore  septi- 
ciBraia  is  properly  regarded  as  a  not  infrequent  and  dangerous  accident 
in  severe  diphtheria,  but  it  is  obviously  very  difficult  to  distinguish 
septic  from  diphtheritic  blood  poisoning,  from  the  symptoms.  Septi- 
ciemia  is  most  apt  to  occur  in  those  cases  in  which  pseudo-membrane 
has  become  dark  gray,  and  friable,  from  decomposition,  producing  an 
icliorous  discharge  and  offensive  breath,  and  in  cases  in  Avhich  blood 
escapes  from  the  capillaries  underneath. 

Absorption  of  the  poisonous  substance  produces  inflammation  of  the 
lymphatic  vessels,  along  which  it  passes,  and  of  the  lymphatic  glands, 
which  these  vessels  enter.  The  adenitis  also  gives  rise  to  inflammation 
of  the  periglandular  connective  tissue,  so  that  the  neck  is  thickened, 
hanl,  and  ten<ler.  If  we  examine  a  gland  Avhicii  is  swollen  and  inflamed 
by  the  toxic  absorption,  w,'  will  fiml  that  its  bloodvessels  are  congested, 
an  I  its  cells  have  undergone  hyperplasia.  The  periglandular  connective 
tissue  is  oedematous,  and  sometimes  infiltrated  with  lymphoid  cell-nuclei 
and  pus-corpuscles.  Capillary  hemorrhages  are  also  common  in  the 
connective  tissue,  and  micrococci  are  found  in  the  lymphatic  vessels, 
lymphatic  glands,  and  in  the  connective  tissue. 

If  (loath  occur  from  obstruction  in  the  air-passages,  the  lungs  will  be 
fouml  mu(;h  reduced  in  size,  the  anterior  sufx'rior  portions  being  pale 
from  lack  of  blood,  and  perhaps  emphysematous,  Avhile  the  posterior 
and  inferior  portions  have  a  dark  red  color,  many  of  the  lobules  being 
collapsed,  and  others  not  only  collapsed  or  semi-collapsed,  but  in  the 
comMiencement  of  pneumonia.  This  difference  in  the  state  of  different 
part-  of  the  lungs,  in  those  who  have  dieil  of  suffocation  in  con-^eipionce 
of  the  presence  of  the  false  membrane  in  the  air-passages,  receives 


308  DIPHTHERIA. 

partial  explanation  from  the  seat  of  the  exudation  in  the  broncliial 
tubes,  for  in  those  who  perish  from  this  cause  the  exudation  is  Ibund 
chiefly  in  such  tubes  as  pass  to  posterior  and  inferior  parts  of  the  or^-an. 
while  such  as  pass  to  the  superior  and  anterior  lobules  remain  free  Irom 
it.  In  some  instances,  in  parts  of  the  lungs  the  pseudo-membrane  can 
be  traced  along  the  minute  bronchial  tubes  into  the  alveoli,  where  it 
forms  a  network — containing  in  its  interstices  pus,  and  sometimes  blood- 
corpuscles,  and  more  or  fewer  micrococci.  "  Pneumonia  is  also  a  common 
complication,  resulting  from  downward  extension  of  the  bronchitis,  or 
occurring  independently  of  the  bronchitis. 

The  muscular  fibres  of  the  heart  in  diphtheria,  as  in  all  acute  infec- 
tious diseases,  are  liable  to  granulo-fattj  degeneration,  so  that  they 
become  softer,  and  have  a  color  which  French  writers  liken  to  that  of  new 
leather  or  coffee  and  milk.  This  degeneration  has  been  observed  only 
in  a  certain  proportion  of  the  more  malignant  cases,  and  is  far  from 
being  uniform.  Any  portion  of  the  heart  may  undergo  this  change. 
It  may  occur  in  the  column?e  carne^e,  or  in  the  walls  of  the  organ. 
White  fibrinous  ante-mortem  clots  are  sometimes  seen  in  the  cavities  of 
the  heart  after  death  from  diphtheria. 

The  blood  in  cases  of  a  severe  type  is  usually  darker  than  in  health, 
and  the  clots  soft.  After  death  from  diphtheritic  laryngitis,  it  is  also 
dark  from  excess  of  carbonic  acid  in  it  The  chemical  changes  which 
the  blood  undergoes  in  diphtheria  are  little  known.  MM.  Andral  and 
Gavarret  found  a  notable  diminution  of  fibrin  in  grave  infectious  dis- 
eases, as  typhoid  fever,  puerperal  fever,  etc.,  and  it  is  not  imjirobable 
that  the  same  is  true  of  diplitheritic  blood,  although  the  exudation  of 
fibrin  is  so  abundant.  M.  Bouchut  and  others  have  found  a  marked 
excess  of  the  Avhite  corpuscles  in  the  blood  in  a  considerable  ])ro})ortion 
of  diphtheritic  patients,  so  that,  instead  of  three  or  four  in  the  field  of 
the  microscope,  as  many  as  sixty  have  been  counted.  M.  Sanne  writes 
of  diphtheria,  "  It  is  necessary  to  recognize  in  the  dark  brown  blood  an 
abnormal  accumulation  of  the  debris  of  the  red  corpuscles,  debris  of 
little  abundance  in  the  normal  state,  augmented  considerably  under  the 
noxious  influence  of  the  diphtheritic  poison,  which  has  rapidly  pro- 
duced destruction  of  a  great  number  of  globules"  {Traite  de  la  Diph- 
thei'ie,  page  107,  Paris,  1877).  Small  extravasations  of  blood  in  various 
organs  are  among  the  most  constant  lesions.  They  have  been  most  fre- 
quently observed  in  the  brain  and  its  meninges,  the  lungs,  s])leen,  and 
kidneys.  In  one  of  the  cases  Avhich  I  examined  after  death  in  the  New 
York  Foundling  Asylum,  the  extravasations  in  and  under  the  gastric 
mucous  membrane  ])roduced  mottling  as  great  as  that  of  tlie  skin  in 
measles.  Tlie  micrococci  enter  the  white  corpuscles,  and  no  doubt 
exert  a  deleterious  eff'ect  on  their  function  and  vitality. 

No  notable  changes  have  thus  far  been  observed  in  the  nervous  centres, 
witli  the  exce])tion  of  the  apoplectic  foci,  and  softening  of  adjacent  brain 
substance,  and  the  congestion  present  when  death  has  resulted  from 
diphtheritic  croup.  But  certain  degenerative  changes  have  been  dis- 
covered in  the  peripheral  nerves,  as  well  as  in  the  muscles  in  ]iarts 
affected  with  diphtheritic  paralysis.  Thus,  in  nerves  from  a  paralyzed 
palate,  certain  nerve  tubes  have  been  observed  nearly  or  quite  destitute 


SYMPTOMS.  309 

of  medullary  matter,  though  this  is  not  common,  but  many  tubes  are 
found  to  contain  fatty  granules,  the  result  of  retrogressive  metamor- 
phosis (MM.  Charcot  and  Yulpian). 

The  liver  does  not  appear  to  be  seriously  engaged  or  its  function  com- 
promised. In  most  acute  infectious  diseases  which  are  fatal  in  conse- 
quence of  blood  poisoning,  the  spleen  is  apt  to  become  softened  and 
somewhat  enlarged,  but  this  does  not  always  occur  in  diphtheria.  It 
will  be  recollected  from  the  cases  related  above  that  the  spleen  may  not 
be  perceptibly  enlarged  or  softened. 

The  kidneys  of  all  the  internal  organs  are  most  frequently  affected, 
as  is  shown  by  the  common  occurrence  of  albuminuria.  Parenchy- 
matous nephritis,  with  the  characteristic  hyperiemia  and  swelling,  is  the 
usual  form  of  kidney  disease  which  complicates  diphtheria.  In  the  albu- 
minous urine  are  found  hyaline  and  granular  casts.  This  inflammation 
may  begin  early  in  grave  cases,  even  as  soon  as  the  first  or  second  day, 
but  its  commencement  is  ordinarily  not  till  toward  the  close  of  the  first 
week  or  in  the  second.  It  occurs  in  the  majority  of  those  severe  cases 
which  prove  fatal  from  blood  poisoning.  Interstitial  nephritis  has  also 
been  not  infrequently  observed  in  parts  of  the  kidney. 

Symptoms. — In  general,  in  the  commencement  of  an  epidemic,  diph- 
theria is  more  severe  and  fatal  than  when  the  epidemic  influence  is 
abating.  The  prominent  symptoms,  such  as  arrest  the  attention  of  the 
fi'iends,  are  often  disproj)ortionate  to  the  gravity  of  the  attack.  Strik- 
ing cases  illustrative  of  this  have  occurred  in  my  practice,  the  friends 
not  supposing  that  there  was  any  serious  ailment,  and  not  seeking 
medical  advice  till  the  fatal  termination  had  nearly  arrived.  The 
initial  syiiiptoins  are^sometimes  mUd,  such  as  chilliness  or  rigorSj  often 
.sTight,  and  succeeded  by  moilerate  febrile  reaction,  languor,  and  perhaps 
more  or  less  headache,  pajn  in  the  limbs  or  back,  and  impaireil  appetite. 
Still  the  patient  may  continue  to  walk  about  as  if  affected  with  slight 
and  temporary  ailment.  Children  thus  affected  frequently  attend  the 
schools,  and  do  immense  harm  in  propagating  the  disease.  The  symp- 
toms in  these  mild  cases  are  often  lUvC  those  from  a  cold,  for  which  light 
attacks  of  diphtheria  are  apt  to  be  mistaken  by  the  friends.  With 
some,  in  mild  as  well  as  severe  diphtheria,  one  of  the  first  symptoms  is 
slight  tenderness  or  a  sensation  of  f|dne§s  in  the  fauces.  A  distin- 
guished clergvman  of  the  Pacific  coast,  who  fell  a  victim  to  this  disease, 
dreamed,  a  few  nights  before  he  complained  of  illness,  that  his  throat 
was  cut.  Doubtless  the  di|)htheriti('  inflammation  had  already  com- 
m*neeil,  so  that  what  seeme*!  a  forewarning  had  a  natural  explanation. 
So  insidious  was  the  commencement  in  this  case  that  the  disease  had 
advanced  beyond  all  hope  of  relief  when  medical  advice  was  first  sought. 
But  in  most  cases,  other  than  those  of  a  very  mild  type,  the  commence- 
ment is  more  severe,  being  attended  by  a  temperature  of  T_02°  or  1.08°, 
or  even  104°,  with  corre.s[)onding  heat  of  surface,  thirst,  languor,  loss 
or  iin]>airinenl  of  appetite,  tenderness  of  throat,  etc.  neliriuni  as  well 
as  eclampsia  may  occur,"l)nt  both  are  rare.  The  febrile  reaction  ordi- 
narily abates  considerably  by  the  close  of  the  second  or  on  the_th[rd^ 
djjj^.  as  I  have  noticed  in  many  observations. 

The  symptoms  of  invasion  have  less  prognostic  value  in  diphtheria 


310  DIPHTHERIA. 

than  in  most  other  infectious  maladies.  We  meet  cases  with  a  severe 
beginning,  attended  by  delirium,  which  terminate  in  apparently  com- 
plete restoration  to  health  in  less  than  a  week,  the  presence  of  the 
characteristic  pellicle  upon  the  fauces  and  the  occui'rence  of  diphtheria 
in  other  members  of  the  family  rendering  the  diagnosis  certain.  On 
the  other  hand,  a  mild  connncncement  sometimes  ushers  in  a  fatal  form 
of  the  disease.  This  is  notably  true  of  those  cases  in  ■which  laryngitis 
supervenes,  as  it  not  infrequently  does  in  cases  Avhich  begin  very  mildly. 

The  fever  which  ushers  in  diphtheria  usually  begins  to  abate  after 
the  second  or  third  day,  and  subsequently,  in  graveTis  well  asTiTbenign 
cases,  there  may  be  but  little  or  even  no  elevation  of  temperature.  The 
diphtheritic  poison  does  not,  therefore,  like  that  of  scarlet  fever,  exhibit 
any  marked  tendency  to  increase  the  animal  heat.  Even  in  jjrofound 
and  fatal  blood  poisoning  in  this  disease,  the  thermometer  shows  the 
normal,  or  scarcely  more  than  normal,  temperature,  so  that  the  inex- 
perienced practitioner  may  be  deceived  in  his  prognosis.  On  the  other 
hand,  a  continued  elevation  of  temperature  with  only  moderate^ngina 
should  lead  the  physician  to  examine  for  some  complication,  perhaps 
nephritis. 

The  tijngue  is  moist,  and  slightly  furred.  The  patient  often  vomits 
in  the  commenceme7Tr,~and  if  this  symptom  cease  or  be  seldom  repeated^ 
it  is  not  grave ;  "But  vomiting  occurring  often,  so  that  the  food  is  re- 
jected, and  due  as  it  fretjuently  is  to  urtiemia,  is  not  uncommon  in 
severe  cases.  The  ^petke  vai'ies.  Repugnance  to  food  characterizes 
many  of  the  gravest  cases,  and,  if  the  child  be  compelled  to  take  it,  it 
is  often  rejected  by  v.oiniting.  Thei'e  are  no  notable  symptoms  refer- 
able to  the  state  of  the  intestines.  The  stools  usually  appear  normal, 
except  as  they  are  changed  by  medicines. 

The  rgspiratoryijiiipaiatus  is  not  involved  in  benign  cases  in  which 
only  the  fauces  are  inflamed.  But  nej^t  to  the  fauces  and  posterior 
buccal  surface,  the  Sehneiderian  nienibrane  is  most  frequently  aflected 
of  all  the  surfaces,  and  when  the  luires  are  inflamed,  and  are  covered 
to  a  greater  or  less  extent  by  the  pseudo-membrane,  there  is  more  or 
less  discharge,  which  may  excoriate  the  uj)per  lip,  and  cause  incrustation 
around  the  entrance  of  the  nostrils.  This  often  renders  respiration 
through  the  nostrils  difficult.  In  cases  having  this  severity  there  is 
usually  at  the  same  time  considerable  faucjal  swejbng,  so  as  to  cause 
guttural  respiration,  which  is  most  marked  in  sleep.  But  the  most 
important  symptoms  pertaining  to  the  respiratory  apparatus,  occur  when 
the  inflammation  attacks  the  laryngeal  or  laryngeal  and  tracheal  surfaces, 
constituting  diphtheritic  croup. 

Diphtheritic  croup  often  occurs  at  the  commencement  of  diphtheria, 
so  as  to  be  and  continue  to  be  the  predominant  inflammation,  but  in 
other  cases  it  supervenes  after  dijjlitheria  has  continued  a  few  days. 
There  are  many  mild  cases,  which  give  no  anxiety  so  long  as  the  inflam- 
mation remains  faucial,  but  in  which  the  whole  aspect  is  within  a  day 
changed  by  the  occurrence  of  croup,  and  the  condition  becomes  one  of 
imminent  danger.  Usually  when  diphtheritic  croup  occurs  there  is  a 
simultaneous  if  not  preexisting  exudation  upon  the  fauces.  Occasion- 
ally in  undoubted  diphtlieria  the  diphtheritic  pellicle  forms  only  upon 


SYMPTOMS.  311 

the  surface  of  the  air-passages  heh)W  the  epiglottis,  while  the  fauces 
present  merely  an  inflammatory  reddening,  and  the  surface  of  the  nares 
is  either  free  from  disease  or  only  reddened.  The  reader  is  referred  to 
the  chapter  relating  to  diphtheritic  croup. 

In  New  York,  as  will  be  seen  l)y  the  table  below,  the  predominant 
inflammation  in  about  one-fourth  of  the  cases  of  dijjlitjlieria  is  the  laryn- 

in  addition  to  the  accelerated  pulse  during  the  febrile  stage  and  the 
slow  and  compressible  pulse  during  the  stage  of  profound  blood  poison- 
ing^ the  cliief~symptoms,  pertaining  to  the  circulatory  system,  relate  to 
the  state  of  the  heart,  and  the  altered  state  of  the  blood  which  gives 
rise  to  hemorrhaixes.  Tbe  ante-mortem  heart-clots,  the  weakened 
action  of  tlie  heart  from  degenerated  muscular  fibres,  the  hemorrhages 
from  the  altered  state  of  the  blood,  indicate  a  very  dangerous  condition 
of  the  circulatory  apparatus. 

Very  little  attention  had  been  bestowed  upon  the  state  of  the  kidneys, 
and  the  character  of  the  urine  in  diphtheria,  till  Mr.  Wade,  of  Birming- 
ham, discovered  all)uuunuria,  since  which  many  observations  in  difterent 
epidemics,  and  localities,  have  established  the  fact  that  albuminuria 
occurs  in  a  majority  of  cases  of  a  severe  type,  and  in  many  cases  of 
diphtheritic  laryngitis  in  which  the  type  is  not  severe.  Two  conditions 
of  the  kidneys  give  rise  to  albuminous  urine,  namely,  nephritis,  which 
is  the  most  common,  and  venous  congestion,  which  occurs  in  cases  of 
embarrassed  circulation,  as  in  certain  cases  of  diphtheritic  laryngitis, 
and  in  obstruction  from  heart  clots.  The  latter  is  comparatively  infre- 
quent. 

During  the  latter  part  of  1875,  and  in  187G,  prior  to  August  1,  I 
endeavored  to  obtain  and  examine  the  urine  in  every  case  of  idiopathic 
dipbtberia,  having  a  clear  diagnosis,  which  came  under  my  notice,  both 
in  family  practice  and  in  institutions  with  which  I  have  an  official  con- 
nection. Ordinarily,  during  the  first  week  of  a  case,  I  found  that  the 
urine  deposited  urates  on  cooling,  and  that  tiie  nitric  acid  test  sliowed  a 
large  relative  quantity  of  urea,  but  I  suspect  that  this  was  due  to  a 
som'.'wbat  diminislicd  quantity  of  vn'ine.  But  the  occurrence  of  albumen 
was  of  cliiff  interest,  and  the  results  of  the  examinations  as  regards  the 
j)resence  or  absence  of  this,  are  recorded  in  the  accompanying  table. 
In  most  cases  the  urine  was  examined  several  times  in  the  course  of  the 
disease,  and,  if  albumen  was  present,  a  microscopic  examination  was 
also  made.  In  nearly  all  the  specimens  which  contained  albumen — all 
but  tbrce  or  f>ur — casts,  usually  granular,  but  now  and  tlion  liyaline, 
niid  sometimes  ))ofh  kimls  in  the  same  specimens,  were  observed.  In 
tbose  cases  of  all)umiiiuria  which  recovered,  there  were  comparatively 
few  casts,  or  none.  If  the  albumen  was  abundant,  and  casts  plentiful, 
the  case  was  usually  fatal,  though  not  perhaps  till  after  the  lapse  of  three 
or  four  weeks,  when  death  occurred  with  symptoms  of  exhaustion, 
[taralysis,  or  feeble  heart-action,  sometimes  with  (edema  of  lungs  super- 
vening sudilenly,  and,  probaltly,  formation  of  heart  clots.  Tin;  albumin- 
uria, unlike  that  of  scarlet  fever,  sehlom  occurred  exce|)t  in  the  grave 
cases;  and  in  the  majority  of  instances  it  did  not  appear  till  near  the 
close  of  the  first  week,  or  in  the  second,  and,  in  a  few  instances,  not  till 


312  DIPHTHERIA. 

a  later  period.  Although  the  albuminuria  of  diphtheria  is  much  more 
grave  than  that  of  scarlet  fever,  it  has  in  my  practice  been  attended  by 
much  less  serous  efllusion  or  dropsy,  often  by  none  "which  was  appreci- 
able. The  urine,  although  containing  a  large  quantity  of  albumen, 
ordinarily  had  nearly  the  normal  appearance,  instead  of  the  smoky  or 
hazy  color  so  common  in  the  albuminous  urine  of  scarlet  fever. 

I.  Cases  aiietided  icii/i  ihe  ii.suni,  memhrnndiiH  exiidntion  i/pon  ihe  -fauceH.  tvlHi  or 
without  cvryza,  and  without  laryngitis  or  with  vJihj  aitarrh<d  Uu-ymjitis ;  fifty- 
eight  cases. 


Tifsult  not 

Died. 

Kecovered. 

staled. 

Total, 

With  iilbiimiiuiria, 

.      13 

5 

1 

19 

AVithoiit  iilbuminuria    . 

.       4 

27 

1 

32 

State  (if  urine  not  recorded 

3 

4 

7 

II.    Cases  attended  ivith  membranous  laryngitis  as   the  predominant  inflammation  ; 

nineteen  cases. 

Died.  Kecovered.  Total. 

With  albuminuria  ....       4  1  5 

Without  alltumiiiuriii  .         .         .       2  4  6 

State  uf  urine  not  recorded     ...       7  1  8 

The  mortality  of  the  cases  embraced  in  the  above  table  was  probably 
larger  than  the  average  in  New  York  practice,  for  several  of  them  were 
seen  in  consultation,  and  their  type  was  severe.  Those  in  which  the 
state  of  the  urine  coukl  not  be  ascertained,  were  usually  clnldren  so 
young  or  so  near  death  tliat  it  was  impossible  to  obtain  sufficient  urine 
for  examination. 

It  is  seen  that  in  New  York,  where  diphtheria  is  endemic,  of  02  cases 
occurring  in  the  course  of  about  ten  mimths,  24  were  attended  by  albu- 
minuria, and  38  were  exempt.  In  a  larger  number  of  cases,  of  which  I 
have  preserved  the  records  since  1870,  I  think  that  the  proportion  of 
albuminous  cases  has  been  about  the  same,  but  obviously  during  epi- 
demics of  a  severe  type  the  proportion  is  larger  than  when  the  type  is 
mild. 

An  efflorescence  is  sometimes  observed  upon  the  skin  during  the  time 
in  wliich  the  temperature  is  exalted.  It  is  the  erythema  fugax  of  der- 
matologists, suddenly  appearing  and  disappearing.  This  eruption,  which 
is  so  common  in  the  febrile  and  inllanimatory  affections  of  childhood, 
does  not  seem  to  present  any  peculiar  cluvracters  in  cliildi'cn.  But  there 
is  another  eruption,  whicii  I  have  several  times  observed,  and  of  whicli 
I  have  preserved  a  drawing  as  it  appeared  in  one  case,  wliich  I  have  no 
doubt  is  due  to  diphtheritic  toxaemia,  or  to  septicaemia  occurring  in  diph- 
theria. It  appears  after  tlie  sixth  or  seventh  day,  in  the  form  of  red 
points  or  spots,  not  more  than  a  line  in  diameter,  and  interspersed  with 
patches  of  hirger  size,  and  irregidar  margins,  one  to  tAvo  inches  in  diam- 
eter. Tbis  roseolar  eruption  is  sliglitly  raised,  like  that  of  measles; 
it  disappears  on  pressure,  and,  in  my  practice,  has  appeared  usually  in 
fatal  cases.  Occasionally  extravasations  of  blood  occur  in  and  under 
the  skin,  like  those  in  the  internal  organs.  The  pallor  of  the  skin 
which  diphtberitic  toxromia  produces  in  tbe  second  and  third  weeks, 
is  known  to  all  wlio  have  had  experience  with  this  disease. 


SYMPTOMS.  313 

Diphtheritic  paralysis  is  described  by  some  writers  as  a  symptom  and 
by  others  as  a  sequel.  It  usually  begins  during  convalescence  in  the 
second  or  third  week  after  tlie  abatement  of  the  inflammatory  symptoms, 
but  sometimes  not  till  a  later  stage.  It  may  on  the  other  hand  appear 
considerably  earlier,  during  the  development  of  the  inilammations,  as 
early  as  the  fifth  or  sixth  da}'',  or  even  as  early  as  the  second  or  third 
day  from  the  beginning  of  the  diphtheria  (Sanne).  When  the  paral- 
ysis begins  at  an  early  period  it  may  cease,  and  reappear  later,  and 
in  other  parts.  Its  commencement  may  not  be  announced  by  any 
symptoms  apart  from  the  loss  of  muscular  power,  but  in  other  cases 
there  is  febrile  movement  with  albuminuria.  The  muscles  most  fre- 
([uently  affected  are  those  of  the  pharynx,  and  upper  part  of  the  larynx. 
The  muscles  of  deglutition  are  sometimes  so  involved,  that  the  food  and 
drinks  are  not  swallowed  till  after  sev^eral  successive  efforts,  and  a  part 
may  be  returned  through  the  nostrils.  A  portion  of  the  food  some- 
times enters  the  larynx,  so  as  to  produce  violent  coughing.  As  we 
observe  tlie  dysphagia,  it  seems  as  if  there  mijst  be  pharyngitis,  which 
renders  deglutition  difficult,  but  on  inspecting  the  fauces  we  find  no 
evidence  of  inflammation.  The  mucous  membrane  ordinarily  appears 
normal,  and  the  nerves  only  are  affected.  The  velum  palati  hangs 
flaccid  and  motionless  like  a  curtain ;  and  the  relaxed  state  of  the 
muscles  at  the  entrance  of  the  larynx  causes  guttural  respiration, 
or  snoring  in  certain  cases,  which  is  especially  marked  during  sleep. 
In  severe  cases  the  difficulty  of  swallowing  may  endanger  suffocation 
from  the  lodgement  of  food  in  the  larynx,  and  inspire  dread  of  taking 
food  on  the  part  of  the  child.  Tickling,  and  even  pricking  the  velum 
fails  to  induce  motion.  In  some  there  is  only  faucial  paralysis,  but  in 
many  the  loss  of  muscular  power  occurs  in  other  parts  also.  Whenever 
it  occurs  elsewhere,  the  pharyngeal  muscles  are  also  usually  involved 
at  the  same  time.  Diphtheritic  paralysis  may  affect  the  motor  muscles 
of  the  eye,  causing  strabismus ;  the  muscles  of  one  side,  causing  hemi- 
plegia ;  of  the  legs,  causing  paraplegia ;  or  of  an  arm  on  one  side  and 
leg  on  the  opposite.  It  does  not  commence  simultaneously  in  the 
various  muscles  which  are  affected,  but  in  succession,  those  first  aflocted 
being  f  )r  the  most  part  the  muscles  of  the  pharynx.  In  some  i)aticnts 
the  nnisdes  of  the  bladder  are  ])aralyzed,  leading  to  retention  of  urine 
or  difficulty  in  passing  it.  Paralysis  in  the  limbs  is  frequently  ])re- 
cedcfl  by  tingling  or  a  sensation  of  formication.  There  is  often  not  a 
total  loss  of  sensation  or  of  motion  in  the  i)aralyz('d  ]iart,  but  more  or 
less  numbness  with  difficulty  rntlicr  tli:in  in)j)ossibility  of  motion.  A 
few  cases  have  Ijccn  reported  in  which  the  paralysis  was  almost  general, 
and  some  believe  tiiat  they  have  met  cases  in  Avhicli  the  heart  wiis 
])aralyzed,  death  occurring  suddenly  and  unexpectedly.  Di".  J.  1>. 
Reynolds  rehites  a  case  in  the  Naio  York  Joiirnal  of  Medicine,  May, 
18(jf),  in  wliich  there  were  not  only  stral)isinus,  jiarlial  paralysis  of  the 
limbs,  and  paralysis  of  tlie  muscles  of  tlic  pharvnx,  so  that  food  was 
regurgitated,  but  the  head  dropj)ed  forward  so  that  the  chin  rested  on 
the  sternum. 

A  majority  of  those  affected  with  jiaralysis  recover,  altliough  few 
regain  complete  use  of  their  muscles  in  less  than  one  month,  ami  many 
do  not  till  between  two  ami  four  months. 


Sli  DIPHTHERIA. 

Defect  of  vision  is  an  occasional  result  of  tliphtheria;  some  liave 
presbyopia ;  others  myopia ;  some  see  double ;  some  are  amaurotic  ; 
while  in  others  one  pupil  is  more  dilated  than  the  other,  or  both  pupils 
are  dilated,  and  feebly  sensitive  to  light.  The  impairment  or  perver- 
sion of  vision  gradually  disappears  as  the  vigor  of  system  returns. 

Various  theories  have  been  advanced  in  explanation  of  the  occur- 
rence of  the  paralysis,  as  that  of  rcilex  irritation  advocated  by  Brown- 
Sequard,  that  of  aniiemia,  etc.  A  careful  examination  of  the  nervous 
centres,  made  in  certain  fatal  cases,  has  revealed  nothing  which  thi-ows 
light  on  its  etiology.  That  the  diphtheritic  virus  causes  paralysis  by 
some  special  action  is  evident,  for  there  is  no  other  infectious  disease 
which  is  attended  and  followed  by  paralysis  so  often  as  diphtheria. 
The  most  plausible  theory  is  that  recently  brought  to  light  by  histo- 
logical examinations,  Avhich  have  shown  that  the  peripheral  nerves  in 
paralyzed  parts  have  undergone  degenerative  changes,  as  mentioned 
above,  so  that  under  the  neurilemma,  Ave  observe  more  or  less  granular 
matter,  in  place  of  the  normal  nerve  tissue,  or  lying  in  this  tissue. 
Among  the  many  anatomical  changes  which  the  specific  princi])le  pro- 
duces, those  in  the  ])eripheral  nerves  must  therefore  be  regarded  as 
important,  since  pathological  changes  in  the  nerves  which  supply 
paralyzed  muscles  sanction  the  belief  that  they  sustain  a  causative 
relation  to  the  paralysis. 

Diagnosis. — In  most  instances  the  diagnosis  of  diphtheria  is  readily 
made  when  the  case  has  continued  a  few  hours,  for  the  characteristic 
false  membrane  is  observed  on  inspection  of  the  fauces.  The  ])hysician 
is  usually  at  his  first  visit  able  to  state  the  nature  of  the  pharyngitis  from 
its  appearance.  But  there  are  cases  Avliich  vary  from  the  typical  form 
in  which  the  diagnosis  is  more  or  less  difficult.  The  confervoid  growth 
of  sprue,  Avlien  occurring  upon  the  fauces,  is  sometimes  mistaken  for 
the  false  membrane  of  diphtheria,  but  the  error  of  mistaking  one  for 
the  other  in  cases  which  I  have  met,  has  ])een  due  to  hasty  and  careless 
examination  rather  than  to  any  real  difficulty  in  the  discrimination. 
The  peculiar  product  of  sprue  has  but  little  depth  and  coherence,  and 
is  readily  detached  without  injury  to  the  mucous  membrane  or  its 
vessels.  If  there  be  any  doubt,  the  differential  diagnosis  can  be  readily 
made  by  the  microscope. 

Follicular  pharyngitis,  like  diphtheria,  commences  with  sluirp  fever, 
wdiich,  lioAvever,  is  ephemeral,  and  is  attended  Avith  the  formation~of 
round  Avhite  masses  in  the  site  of  the  follicles,  usually  oyer  the  tonsils 
qii1y«  These  masses  do  jiotoccur  in  patches,  like  those  of  diphtheria, 
except  Avhen  two  or  three  are  in  close  proximity  and  unite,  but  at  the 
same  time  a  sufficient  number  are  discrete  to  establish  the  diagnosis. 
Follicular  pharyngitis  often  occurs  in  several  niemljers  of  a  family  at 
the  same  time,  involves  no  danger,  and  is  quickly  cured.  The  Avhite 
masses  consist  of  the  inspissated  secretion  of  the  follicles  mixed  Avith 
epithelial  cells. 

Prognosis. — No  infectious  disease  presents  greater  difference  in 
type  or  severity.  In  mild  epidemics,  Avith  moderate  fever,  slight 
faucial  swelling,  and  little  extent  of  the  pseudo-membrane,  a  large 
majority  recover,  and  Avould  recover  even  Avithout  treatment.      Uncer- 


PROGNOSIS.  315 

tainty  of  prognosis,  of  which  even  physicians  of  ample  experience  com- 
plain, is  largely  due  to  the  fact  that  diphtheria  terminates  fiitally  in 
several  distinct  ways.  Hence  while  the  patient  may  be  secure  as 
regards  tiie  more  manifest  and  common  conditions  of  danger,  so  as  to 
justify  a  favorable  prognosis  in  the  opinion  of  the  physician  who  attends 
him,  the  fatal  result  may  suddenly  occur  from  some  unseen  and  unsus- 
pected cause. 

Death  in  diphtheria  may  result  from — 

1st.   Diphtheritic  blood-poisoning. 

2d.  Probably,  also,  from  septic  blood-poisoning  produced  by  absorp- 
tion from  the  under  surface  of  the  decomposing  pscudo-membi'anc.  But 
it  is  difficult  to  distinguish  the  constitutional  effects  of  sepsis  from  those 
produced  by  the  diphtheritic  poison.  Septic  poisoning  is  obviously 
most  apt  to  occur  in  those  cases  in  which  the  pseudo-membrane  is  ex- 
tensive, and  deeply  emljedded,  and  its  decomposition  attended  by  an 
offensive  effluvium.  Cervical  cellulitis,  and  adenitis,  which,  when 
severe,  cause  very  considerable  swelling  of  the  neck,  appear  to  be  often, 
if  not  usually,  due  to  septic  absorption  from  the  faucial  surface,  the  in- 
flammation extending  from  the  absorbents  to  the  glands  and  connective 
tissue.  Considerable  tumefaction  of  the  neck,  therefore,  seldom  occurs 
in  diphtheria  or  scarlet  fever,  without  manifest  symptoms  of  toxirmia, 
and  it  is  to  be  regarded  as  a  sign  of  its  presence. 

3d.    Obstructive  larj^ngitis. 

4th.   Uraemia. 

5th.  Sudden  failure  of  the  heart's  action,  either  from  the  anaemia, 
and  general  feebleness,  from  granulo-fatty  degeneration  of  the  muscular 
fibres  of  the  heart,  which  is  liable  to  occur  in  all  infectious  diseases  of  a 
malignant  type,  or  from  ante-mortem  heart  clots. 

6tli.  Suddenly  develope<l  passive  congestion  and  oedema  of  the 
lungs,  probably  due  to  feebleness  of  the  heart's  action,  or  to  ]iaralysis 
of  the  respiratory  muscles.  I  have  known  death  to  occur  aj)i)arently 
from  this  cause  during  the  period  of  supposed  convalescence,  and  when 
the  visits  of  the  physician  had  been  discontinued.  Thus  in  a  case  in 
my  practice,  symptoms  of  oedema  pulmonum  (moist  ral-es  in  both  sides 
of  the  chest,  and  embarrassed  breathing)  suddenly  occurred  nearly  one 
month  after  the  disappearance  of  the  faucial  pseudo-meml)rane  and  in- 
flammation. The  urine,  wiiich  liad  contained  considerable  albumen 
during  the  active  period  of  the  malady,  had  for  some  time  shown  no 
trace,  or  but  slight  trace,  of  this  princifile  by  the  ))roper  tests.  By 
active  stimulation  these  symptoms  entirely  disapj)earcd  in  a  few  iiours, 
and  the  heart's  action  seemed  normal,  unless  a  little  weakened.  On 
the  following  day  the  same  symptoms  reajipeared,  and  death  occurred 
before  I  was  able  to  reach  the  house. 

That  physician  obviously  is  least  apt  to  err  in  prognosis,  who  recog- 
nizes the  fact  that  patients  are  liable  to  perish  in  any  of  these;  dilVerent 
ways,  and  carefully  examines  in  reference  to  all  the  conditions  which 
involve  danger.  Many  physicians,  as  I  have  had  the  opportunity  to 
observe,  are  remiss  in  not  examining  more  frcfpiently  the  urine  of  di|»h- 
theritic  patients,  for  there  is  often  a  large  amount  of  albumen  in  the 


316  DIPHTHERIA. 

urine  in  diplitlieria,  indicating  a  poisonous  quantity  of  urea  in  the  blood, 
and  yet  the  a})pearance  of"  the  urine  to  the  naked  eye  is  probably  normal. 

Among  the  symptoms  ^^■hicl^  render  the  prognosis  unfavorable  are, 
repugnance  to  food,  vomiting,  pallor  of  countenance,  with  progressive 
weakness  and  emaciation  from  the  blood-poisoning  ;  a  large  amount  of 
albumen  with  casts  in  the  urine,  showinii  uriemia,  to  Avhich  the  voinitins: 
is  sometimes,  but  not  always,  attributable;  a  free  discharge  from  the 
nostrils,  or  occlusion  of  them  by  inflammatory  thickening,  and  exuda- 
tion, showing  that  a  considerable  portion  of  the  Schneiderian  membrane 
is  involved,  hemorrhage  from  the  nostrils  or  fauces,  and  obstructed  res- 
piration. In  diphtheritic  laryngitis,  attended  by  obstructed  respiration, 
a  large  majority  have  thus  far  died,  whether  treated  by  the  most  approved 
inhalations  or  by  tracheotomy.  One,  at  least,  of  the  above  symptoms 
lias  been  present  in  most  of  the  fatal  cases  which  I  have  observed. 

Treatment. — Although  diphtheria  has  been  one  of  the  most  common 
of  the  severe  infectious  maladies  in  this  country  during  the  last  twenty- 
five  years,  physicians  are  for  from  agreeing  in  reference  to  the  proper 
mode  of  treatment.  This  difference  of  opinion  respecting  the  therapeutic 
reijuii-ements  is  due  in  part  to  difference  in  the  type  of  the  malady  in 
difterent  localities  and  epidemics,  in  part  to  difference  in  diagnosis,  so 
that  one  considers  a  case  to  be  diphtheritic,  which  another  regards  as  a 
non-specific  inflammation,  but  more  to  the  fact  that  different  theories  are 
held  respecting  the  cause  and  nature  of  diphtheria.  Scarcely  any  other 
disease  presents  such  a  diversity  in  type  as  diphtheria,  from  cases  so 
mild  that  nearly  all  recover,  whatever  the  measures  employed,  to  those 
so  severe  that  a  large  proportion  die  under  the  best  possible  treatment ; 
and  this  difference  in  type  may  be  observed  in  cases  occurring  at  the 
same  time  in  a  great  city  like  New  York,  and  even  in  the  cases  which 
two  physicians  practising  near  each  other  may  be  called  to  treat.  Hence 
one  physician  recommends  with  confidence  a  medicine  or  mode  of  treat- 
ment as  eminently  successful  in  his  hands,  of  which  another  speaks  dis- 
paragingly. 

The  germ  theory,  which  has  been  described  above,  according  to  which 
diphtheria  i-5  produced  by  mici'oorganisms,  has  had  a  marked  influence  on 
the  therapeutics  of  this  malady.  Acceptance  of  the  germ  theory  does 
not  require  us  to  believe  that  di])htheria  is  primarily  local,  for  these 
orixanisms  mijrht  enter  and  infect  the  blood  throuo-h  the  luniis,  before 
any  symptom  occurred,  but  as  it  is  ordinarily  promulgated,  we  are  taught 
that  these  organisms  alight  upon  one  of  the  exposed  surfaces,  usually  the 
fauces,  where  they  excite  local  inflammatory  action,  and  if  not  promptly 
destroyed  they  soon  penetrate  the  tissues,  enter  the  blood,  and  estab- 
lish a  constitutional  disease.  Acceptance  of  this  theory  evidently  leads 
to  the  emifloyment  of  germicide  medicines,  the  so-called  antiseptics, 
or  anti-ferments,  externally  and  internally,  to  arrest  and  destroy  the 
vegetable  growth,  their  local  use  sufficing,  according  to  the  theory,  in 
the  early  stage,  when  these  organisms  have  passed  no  further  than  the 
surface,  but  their  internal  use  being  required  in  addition,  if  the  malady 
has  continued  longer,  and  the  disease  become  general.  Hence,  in  pro- 
portion as  this  doctrine  came  in  vogue,  carljolic  acid,  chlorine  prepara- 
tions, bromine,  the  sulphites,  phenic  acid,  and,  as  the  best  representative 


TREATMENT.  317 

of  this  class  of  medicines,  and  most  powerful  antiseptic,  salicylic  acid, 
attained  at  once  prominence  as  the  agents  which  would  be  most  likely 
to  cure  diphtheria,  by  destroying  the  cause.  A  solution  of  bromine  and 
bromide  of  potassium  having  been  used  with  apparent  good  results  in 
the  antiseptic  surgery  of  the  army  during  the  late  war,  has  obtained 
under  the  influence  of  this  theory  some  reputation  in  Kew  York  as  a 
remedy  for  diphtheria,  employed  externally  and  internally,  and  without 
the  aid  of  other  therapeutic  agents.  A  certain  number  of  drops  are 
administered  internally  every  hour,  or  second  hour,  properly  diluted, 
and  the  same  medicine  undiluted,  or  with  less  dilution,  is  applied  to  the 
fauces  with  a  brush  at  regular  intervals. 

But  experience,  if  sufficiently  extensive,  is  the  safe  guide  in  thera- 
peutics, and  internal  antiseptic  measures  have  not  seemed,  so  far  as 
my  observations  extend,  to  exert  any  marked  controlling  effect  on  the 
course  of  diphtheria. 

Thus,  a  child  of  four  years,  whose  case  I  was  able  to  follow,  took,  almost 
from  the  beginning  of  the  sickness,  a  mixture  of  potassa  and  iron  on  the 
first  hour,  two  grains  of  quinine  on  the  second  hour,  and  three  grains  of 
salicylic  acid  on  the  third  hour,  and  this  treatment  Avas  continued  night 
and  day ;  and  yet  this  child,  having  from  the  first  taken  sixteen  grains 
of  quinine,  twenty-four  of  salicylic  acid,  besides  the  potash  and  iron 
daily,  <lied  after  ciglit  days  with  profound  blood  poisoning,  having  had 
many  extravasations  of  blood. 

This  case,  which  presented  the  ordinary  history  of  fatal  diphtheria, 
did  not  seem  to  be  materially  modified  by  the  internal  antiseptic  treat- 
ment. It  would  apparently  have  done  as  well  without  it.  It  is  but  one 
case,  tliough  an  average  example,  and  I  have  not  observed  any  other  in 
which  the  internal  use  of  antiseptics  seemed  to  produce  a  curative  effect. 
My  knowledge,  hoAvever,  of  the  bromine  treatment  is  limited  to  the  four 
children  of  one  family,  and  to  the  effects  of  its  use,  Avliich  have  been 
reported  to  me  by  others. 

Between  December,  187'"),  and  July,  1878, 1  examined  minutely,  and 
])reserved  records  of,  104  cases  of  jirimary  diphtlieria,  occurring  either 
in  my  j)rivate  practice,  or  seen  by  me  in  consultation,  besides  observing 
cases,  and  witnessing  autopsies  in  the  New  York  Foundling  Asylum, 
Avhere  dijditheria  was  endemic  nearly  tAvo  years.  From  these  observa- 
tions, and  from  the  many  cases  Avhich  I  have  since  observed,  I  am  per- 
suaded that,  in  order  to  secure  the  best  treatment,  constitutional  and 
local,  of  diplitlieria,  it  is  necessary  that  the  physician  should  accept  the 
f)llowing  ])ropositions: 

1st.  The  specific  principle  of  diphtheria,  in  all  probability,  quickly 
enters  the  blood,  in  ordinary  cases.  And  after  an  incubative  jjcriod, 
Avhicli  varies  from  a  few  hours  to  seven  or  eight  days,  jiroduces  the 
symptoms  Avhich  characterize  the  disease. 

2d.  As  in  vaccinia  the  system  is  infected  as  soon  as  the  vaccine  i'ru|i- 
tion  appears,  so  in  diphtheria  tjie  blood  is  infected  as  soon  as  the  pharyn- 
gitis and  pseudo-membrane  occur.  Their  intimate  relation  to  the  circu- 
latory system,  and  especially  the  fact  that  raising  the  pseudo-membrane 
lacerates  capillaries,  and  causes  bleeding,  prevents  our  believing  other- 
wise. 


818  DTPIITIIERIA, 

3d,  The  blood  poisoning  is  probably  sonietimcs  septic,  but  as  it  ordin- 
arily occurs,  it  is  produced  by  a  specific  principle  peculiar  to  diphtheria. 

4th.  Facts  do  not  justify  the  belief  that  the  system  can  be  ])rotected 
by  antiseptic  or  preservative  medicines  administered  internally.  A 
quantity  of  this  kind  of  medicine,  introduced  into  the  system,  suiRcient 
to  preserve  the  blood  and  tissues  from  the  action  of  the  diphtheritic 
virus,  would,  there  is  reason  to  think,  be  so  large  as  to  arrest  molec- 
ular action,  and  therefore  the  functions  of  organs,  and  occasion  death. 

r)th.  There  is  no  known  antidote  for  diphtheria,  in  the  sense  in  which 
quinia  is  an  antidote  for  malarial  diseases,  and  no  more  probability  that 
such  an  antidote  will  be  discovered  than  ibr  scarlet  fever  or  typhoid 
fever. 

6th.  Diphtheria,  like  erysipelas,  has  no  fixed  duration.  It  may  cease 
in  two  or  three  days,  or  continue  as  many  weeks ;  but  the  specific  poison 
acts  with  more  intensity  in  the  commencement  than  subsequently,  and 
its  energy  gradually  abates.  Hence,  diphtheritic  inflammation,  which 
arises  in  the  beginning  of  diphtheria,  as  laryngitis,  is  more  severe  and 
dangerous  than  when  the  malady  has  continued  a  few  days. 

7th.  The  indication  of  treatment  is  to  sustain  the  patient  by  the  most 
nutritious  diet,  by  tonics,  and  stimulants ;  and  to  employ  other  meas- 
ures, general  and  local,  as  adjuvants,  to  meet  special  indications  which 
may  arise.  The  rules  of  treatment  ajipropriate  for  scarlet  fever,  apply 
for  the  most  part  to  diphtheria.  Local  treatment  of  the  inflammations 
should  be  unirritating,  and  designed  to  prevent  putrefactive  changes  and 
septic  poisoning.  Irritating  applications  which  produce  ])ain  lasting 
more  than  a  few  minutes,  or  which  increase  the  area  or  degree  of  redness, 
are  apt  to  do  harm,  and  increase  the  extent  and  thickness  of  the  pseudo- 
membrane. 

General  Treatment. — This  may  be  conveniently  considered  under 
the  three  heads,  food,  stimulants,  and  tonics.  All  physicians  of  exj)eri- 
ence  recognize  the  importance  of  the  use  of  the  most  nutritious  and 
easily  digested  food,  and  the  preservation  of  the  appetite — fcA- the  safety 
of  the  patient  requires  that  he  should  retain,  as  far  as  possible,  his  flesh 
and  strength.  The  more  nutritious  and  easily  digested  the  food,  given 
in  sufficient  quantity,  with  the  appetite  preserved,  the  less,  obviously, 
the  danger  of  the  fatal  prostration  which  so  frequently  occurs  suddenly 
and  unexpectedly  in  grave  cases.  Beef-tea,  or  the  expressed  juice  of 
meat,  milk  with  farinaceous  food,  etc.,  should  be  administered  every 
two  or  three  hours,  or  to  the  full  extent,  Avithout  overtaxing  digestion. 
Failure  of  the  appetite,  and  refusal  to  take  food,  are  justly  regarded  as 
very  unfiivorable  signs.  One  objection  to  the  use  of  the  brush,  instead 
of  spraying  the  fauces  with  the  atomizer,  is  that  it  is  more  apt  to  pro- 
voke vomiting,  by  which  nutriment,  that  is  so  much  required,  is  lost. 
In  malignant  cases  of  diphtheria,  as  in  scarlet  fever  of  a  similar  type, 
patients  are  sometimes  allowed  to  slumber  too  long  without  nutriment. 
It  is  the  slumber  of  toxaemia,  and  should  be  interrupted  at  stated  times, 
in  order  to  give  food. 

Stimulants. — M.  Sanne,  in  his  treatise  on  diphtheria,  says: 
"  De  tous  les  antiseptiques  donnes  'X  I'interieur,  I'alcool  est  de  beau- 
coup  le  plus  sur.     Plus  I'infection  est  prononce,  plus  il  faut  insister 


STi:\IULAXTS.  319 

sur  les  composes  alcooliques."  He  states  that  Briclieteau  reports 
the  history  of  a  patient,  who  took  daily,  during  diphtheria,  a  hottle 
and  a  lialf  of  the  wine  of  Bordeaux,  without  the  least  symptom  of  in- 
toxication or  headache.  A  somewhat  similar  case  was  reported  to  me, 
in  which  nearly  a  bottle  of  brandy  was  given  in  less  than  twenty-four 
hours,  without  any  ill-effect,  and  an  apparent  good  result  on  the  general 
course  of  the  disease.  The  same  rule  holds  true  in  diphtheria  as  in 
other  acute  infectious  maladies,  that  while  mild  cases  do  well  without 
alcoholic  stimulants,  they  are  required  in  cases  of  a  severe  type,  and 
should  be  administered  in  large  and  frequent  doses,  whenc^'er  pallor  and 
loss  of  appetite,  or  of  strength  and  flesh,  indicate  danger  from  the  diph- 
theritic or  septic  infection.  It  matters  little  how  the  stimulant  is  admin- 
istered, whether  milk-punch  or  wine-whey,  provided  that  the  proper 
quantity  is  employed.  If  given  early  and  frequently  in  grave  cases, 
as,  for  example,  one  teaspoonful  every  half  hour  of  brandy  or  Bourbon 
whiskey,  it  does  seem  to  have  a  tendency  to  render  the  disease  more 
tractable.  But  to  be  instrumental  in  saving  life  in  malignant  cases, 
it  must  be  given  boldly  from  the  start.  If  there  be  marked  diph- 
theritic toxaemia  when  its  use  is  commenced  it  will  not  save  life,  but  it 
may  prolong  it.  Although  an  advocate  of  the  liberal  use  of  alcohol  I 
cannot  regard  this  agent  as  a  specific.  When  I  commenced  serving  in 
the  New  York  Foundling  Asylum  in  May,  1878,  the  quarantine  wards 
contained  four  children,  between  the  ages  of  three  and  five  years,  who 
had  been  sick  a  few  days  with  severe  diphtheria,  and  it  was  evident  at 
a  glance  that  they  must  soon  perish  with  the  ordinary  mild  sustaining 
treatment.  Quinine,  iron,  the  most  nutritious  food,  and  a  moderate 
amount  of  alcoholic  stimulants  were  being  given,  and  we  determined  to 
increase  the  Bourbon  whiskey  to  one  teaspoonful  every  twenty  to  thirty 
minutes,  day  and  night.  Nevertheless,  whatever  the  result  might  have 
been  with  the  earlier  commencement  of  this  treatment,  the  blood  poison- 
ing was  now  too  profound,  and  one  after  the  other  died.  That  intoxi- 
cation is  so  seldom  produced  in  this  disease  by  frequent  and  large  doses 
of  the  alcoholic  compounds  is  due  partly  to  the  quick  elimination  of 
such  substances  from  the  system,  and  in  part,  probably,  to  the  nature 
of  diphtheria. 

In  fulfilling  the  indication  for  sustaining  treatment,  the  vegetable 
tonics  have  been  long  used,  especially  cinchona  and  its  alkaloid  ])rinciple 
quinia.  The  compound  tincture  of  cinchona,  and  the  flui<l  extract,  have 
been  used  and  recommended  by  pliysicians  of  experience  ;  but  of  vege- 
table agents,  (piinia  has  long  been  and  still  is  more  frequently  prescribed 
than  all  others.  But  the  doses  employed  vary  greatly  in  size  and  fre- 
quency, in  the  practice  of  different  physicians.  It  is  administered  in 
large  doses  for  its  antipyretic  effect,  so  that  twenty  or  thirty  grains  arc 
given  daily,  and  in  small  doses,  as  one  to  two  grains  every  fourlh  hour, 
for  its  tonic  effect.  That  there  is  nothing  antagonistic  in  the  action  of 
([uinine  to  the  diplitheritic  virus,  and  that  it  is  beneficial  in  tlie  same 
way,  and  no  furtiier,  than  in  other  acute  infectious  diseases,  is,  I  think, 
generally  admitted  by  the  profession.  Large  and  frequent  doses  appar- 
ently produce  no  amelioration  in  the  severity  of  the  disease,  or  diminish 


320  DinrniERiA. 

the  degree  of  blood-poisoning,  as  is  sllo^Yn  by  cases  like  the  following, 
which  are  not  infrequent  during  severe  epidemics. 

C,  aged  four  years,  male,  was  examined  by  me  in  consultation,  on 
February  10,  1876.  I  learned  that  he  had  ap|)arently  contracted  diph- 
theria from  the  escape  of  sewer-gas  through  a  defective  trap  in  the  little 
room  where  he  slept,  and  that  the  disease  began  after  midday'on  February 
6th,  with  fever.  At  10  p.  m.  of  the  same  day,  when  visited  by  tiie  family 
physician,  the  temperature  was  10o°,  and  the  fauces  were  red,  but  without 
any  psuedo-membrane.  Four  grains  of  quinia  were  ordered  to  be  given 
every  two  hours,  and  ten  drops  of  the  tincture  of  the  cldoride  of  iron, 
with  two  grains  of  the  chlorate  of  potassium,  to  be  given  three  times 
hourly.  On  the  7th  the  exudation  covered  both  tonsils  and  the  half 
arches;  temp.  102v°  ;  evening  temp.  100^;  pulse  128.  8th.  Is  playful; 
pulse  100  ;  has  slight  swelling  of  the  cervical  glands  ;  evening,  some  ex- 
tension upward  of  the  pseudo-membrane  ;  has  vomiting.  Uth.  Pulse  144; 
vomits  often.  10th.  At  3  p.  m.  began  to  grow  worse ;  pharynx  and  nos- 
trils covered  Avith  the  exudation.  From  this  time  the  case  ra[)idl}' 
advanced  to  a  fatal  termination. 

It  was  impossible  at  the  time  of  my  visit  to  obtain  the  urine  for  exami 
nation  and  death  occurred  a  few  hours  afterwards.  Forty-eight  grains 
of  quinia  daily,  administered  from  the  first  day,  had  no  appreciable  effect 
in  staying  the  fatal  progress  cf  the  malady,  had  no  such  effect  as  would 
be  likely  to  follow  were  its  action  antidotal,  or  did  it  tend  to  prevent  or 
diminish  the  blood  poisoning.  As  an  antipyretic,  I  am  justified  in 
saying  from  our  experience  in  the  New  York  Infant  Asylum  and  New 
York  Foundling  Asylum,  that  quinine  is  inferior  to  salicylate  of  sodium, 
both  in  svmptomatic  and  constitutional  fevers;  but  as  it  is  a  tonic,  and 
does  not  impair  digestion,  it  is  to  be  preferred  to  any  other  medicine  in 
diphtheria,  when  the  febrile  movement  is  so  great  that  an  antipyretic  is 
needed.  Great  elevation  of  temperature,  however,  seldom  occurs  in 
diphtheria  after  the  third  or  fourth  day,  for  when  symptoms  of  blood 
poisoning  occur  the  temperature  is  apt  to  fall,  so  that  in  profound  toxaemia 
it  is  often  not  more  than  101°  or  102°,  and  the  indication  for  quinine 
is  then  not  for  its  antipyretic  but  tonic  action.  The  following  is  a  pre- 
scription for  this  agent  as  a  tonic  for  a  child  of  five  years. 

R. — Q'linife  sulphat ^ss. 

Syr.  pruni  virginiani ; 

or, 
Elix.  tarax.  comp. 3!]. — Misce. 

Give  one  tcaspoonful  every  two  to  four  hours. 

All  physicians  Avho  are  familiar  with  diphtheria  have  noticed  the 
pallor,  loss  of  appetite,  flesh  and  strength,  wiiich  conmience  before  the 
close  of  the  first  week  in  severe  cases,  and  which  are  always  unfavorable 
S3''mptoms,  indicating,  as  they  do,  rapid  and  progressive  deterioration  of 
the  blood.  The  use  of  iron  is  at  once  suggested  as  the  proper  medicinal 
remedy  to  arrest  this  blood  change,  from  its  known  effect  in  increasing 
the  number  of  red  blood-corpuscles,  and  the  quantity  of  coloring  matter  in 
these  corpuscles,  and  the  nutritive  elements  in  the  blood.     By  its  effect 


STIMULANTS.  321 

on  the  red  corpuscles,  which  are  the  carriers  of  oxygen,  it  increases  the 
functional  activity  of  organs,  and  improves  the  general  nutrition.  The 
ferruginous  prei»arations,  therefore,  hold  an  important  place  in  the 
therapeutics  of  diphtheria.  The  one  which  has  long  stood  the  test  of 
experience,  and  is  noAV  commonly  used,  is  the  tincture  of  the  chloride  of 
iron.  It  should  be  given  in  large  and  frequent  doses,  as  five  drops 
hourly,  to  a  child  of  three  to  five  years. 

The  inflammations,  so  far  as  they  are  accessible,  should  be  treated  by 
local  measures,  but  we  may  combine  with  the  iron  one  which  exerts  a 
decidedly  curative  action  on  buccal  and  pliaryngeal  inflammations,  which 
is  a  solvent  of  pseudo-membranes,  and  which,  after  it  enters  the  system, 
being  largely  eliminated  from  the  salivary  glands,  continues  after  the 
dose  is  taken  to  have  effect  on  the  inflamed  surface  of  the  buccal  cavity 
and  fauces.  This  medicine,  namely,  the  chlorate  of  potassium,  has  of 
late  years  become  a  domestic  remedy,  but  the  laity  should  be  cautioned 
in  reference  to  its  use.  It  is  an  irritant  to  the  kidneys  in  large  doses, 
producing  intense  inflammatory  congestion  of^ these  organs  and  arresting 
their  function.  The  melancholy  fate  of  Dr.  Fountaine  more  than  a 
quarter  of  a  century  since,  whose  life  was  sacrificed  by  an  experimental 
dose  of  one  ounce  of  this  agent,  is  remembered  by  the  older  physicians. 
A  few  years  since  in  my  own  practice  a  child  of  about  three  years,  witli 
an  active  pharyngitis,  ])rol)ably  diphtlieritic,  and  a  temperature  of  108°, 
Avas  allowe«l  to  quench  its  thirst  between  evening  and  morning,  by  drink- 
ing from  a  small  pitcher  in  Avhich  three  drachms  of  chlorate  of  potassium 
were  dissolved.  In  the  morning  I  was  summoned  in  haste,  and  found 
the  surface  of  the  patient  cold  and  blue,  and  pulse  feeble.  The  urine 
was  totally  suppressed,  and  instead  of  it  a  few  drops  of  blood  passed 
from  the  urethra.  Deatli  occurred  before  night.  The  chlorate  had 
apparently  produced  some  irritation  u})on  the  intestinal  surface,  but  tlie 
fatal  result  was  evidently  due  to  the  state  of  tlic  kidneys.  A  child  of 
three  years  should  not  take  more  than  three  grains  at  a  dose,  and  no 
more  than  one  drachm  in  twenty-four  hours.  The  following  will  be 
found  useful  ])re.scriptions  : 

R. — Tine,  forri  chloridi        .         .         .         .         .         •      .tU- 

Potas.  chlnrat.      .......      ^'\. 

Syr.  simplic.  .......      3iv. — Misce. 

Dose,  one  tcaspoonful  evpry  hour  to  two  hours  for  a  cliild  <>f  three  years.  In 
place  of  the  simple  syrup  tiirec  parts  of  water  and  one  of  glycerine  may  be  em- 
ployed. 

li  . — Tine,  fcrri  (■hlf)ridi        ......  ^t^ij. 

Acidi  siilphiirosi  ......  ^]. 

Potas   clilorat.      .......  i}. 

Glycerin  ID     .         .         .         .         .         .         .         .  z^!'. 

Aq.  caliis      ......         q.«.  ad.  .^iij. — ^risce. 

Dose,  one  teaspoonful  every  hour  to  two  liours  for  a  cliild  of  three  years. 

The  citrate  of  iron  and  ammonia  alone,  or  in  comI)iiiatiou  with  car- 
bonate of  auimotiium,  may  be  given  in  two-grain  (bwes,  dissolved  in 
simple  syrup,  in  place  of  the  above  mixture,  wlien  the  inflammation  of 
the  fauces  has  considerably  abated  or  is  moderate  ;  or  the  beef,  iron,  ami 
wine  of  the  shops  may  be  given  every  hour  or  second  hour.     If  the 

21 


322  DIPHTHERIA. 

patient  improve,  and  the  disease  begin  to  decline,  the  intervals  between 
the  doses  may  be  lengthened,  but  the  tonic  should  not  be  entirely  dis- 
continued until  the  ])atient  is  far  advanced  in  recovery,  on  account  of 
the  dangerous  sequehi3  -which  take  their  origin  in  an  impoverished  state 
of  the  blood. 

Local  Treatment. — It  is  important  to  keep  in  mind  tlie  purpose 
for  which  local  measures  should  be  employed,  as  stated  above.  It  is  to 
reduce  the  inilammation  of  the  mucous  surfaces,  and  destroy  the  diph- 
theritic jioison  and  contagious  properties  in  the  pseudo-membrane,  and 
to  destroy  the  septic  poison,  and  prevent  its  absorption,  if  any  form. 
Forcible  removal  of  the  pseudo-membrane,  irritating  applications,  the 
use  of  a  sponge  or  other  rough  instrument,  for  making  the  applications, 
should  be  avoided  as  likely  to  do  harm.  The  applications  should  be 
made  either  with  a  large  camel's-hair  pencil,  or,  l)etter  for  most  of  the 
mixtures  employed,  Avith  the  atomizer.  The  hand  atomizer,  like  Rich- 
ardson's hard  rubber,  or  Delano's,  which  is  of  simple  construction,  while 
it  carries  a  heavy  spray  from  the  curved  tube,  which  is  introduced  over 
the  tongue,  is  very  useful. 

Half  a  dozen  to  a  dozen  compressions  of  the  bulb  of  the  hand  atom- 
izer cover  the  surflice  of  the  throat  more  effectually  with  the  liquid  than 
can  be  done  by  several  applications  of  the  brush,  and  it  is  usually  not 
dreaded  by  the  patient.  Diminution  in  size  of  the  pseudo-membrane 
under  the  use  of  the  spray  is  a  fivorable  sign,  but  if  it  do  not  diminish, 
its  presence  can  do  little  harm,  provided  that  it  is  properly  disinfected. 

The  steam  atomizer  may  also  be  used,  and  in  some  cases  it  is  more 
convenient  than  that  worked  by  the  hand,  but  the  medicine  employed 
in  it  is  necessarily  much  diluted  by  the  steam  from  the  boiler,  unless 
it  be  of  such  a  nature  that  it  can  be  used  in  both  cup  and  boiler.  The 
steam  atomizer  possesses  the  advantage  of  producing^  a  steady  spray, 
without  exciting  or  disturbing  the  patient,  so  that  it  can  be  inhaled 
even  during  sleep,  but  it  is  best  often  to  supplement  its  action  by  the 
hand  instrument.  The  hand  atomizer  is  less  apt  to  be  clogged  than 
the  delicate  glass  points  of  the  steam  instrument,  and  will  vaporize  a 
thicker  liquid.  This  is  an  important  advantage,  especially  in  using 
the  lime-water  for  inhalation  in  croup,  since  it  can  be  employed  in  the 
hand  atomizer  even  when  it  presents  a  milky  appearance  from  the 
amount  of  lime. 

At  a  recent  meeting  of  the  New  York  Pathological  Society  I  pre- 
sented a  specimen  showing  the  diphtheritic  exudation,  and  a  discussion 
arose  as  to  what  is  the  safest  and  most  efficient  solvent  of  the  false 
membrane,  full  and  exact  knowledge  of  which  is  very  important,  espe- 
cially for  correct  treatment  of  diphtheritic  croup.  Chlorate  of  potas- 
sium, pepsin,  lactic  acid,  and  lime,  arc  solvents  of  pseudo-meml)rane:-?, 
and  after  the  meeting  of  the  Pathological  Society  Dr.  Chadbourne, 
resident  physician  of  the  New  York  Foundling  Asylum,  and  myself, 
determined  to  ascertain  experimentally  which  is  the  best  solvent.  We 
employed  reliable  liquid  pepsin,  acidulated  with  lactic  acid,  thirty 
drops  to  the  ounce,  for  one  solvent,  and  the  officinal  lime-Avater  for  the 
other.  Equal  portions  of  pseudo-membrane,  removed  from  the  larynx 
in  a  fatal  case  of  diphtheritic  croup,  were  added  to  the  same  quantity 


LOCAL    TREATMENT,  323 

of  these  liquids.  The  lime-watei*  produced  complete  solution  in  about 
twenty-five  minutes,  while  the  lactic  acid  and  pepsin  required  more 
time.  I  have  repeated  the  experiment  since,  with  a  similar  result,  and 
have  employed  the  lime-water  mixed  with  about  one-fourth  its  quantity 
of  carbonic  acid  water,  but  this  did  not  seem  to  impair  materially  the 
solvent  power  of  the  lime.  This  last  experiment  was  made  in  order  to 
determine  whether  the  carbonic  acid,  which  passes  over  the  pseudo- 
membrane  in  each  expiration,  impaired  the  solvent  action  of  the  lime. 

Therefore  in  the  local  treatment  of  diphtheritic  pharyngitis,  plain 
lime-water  is  one  of  the  best  solvents  of  the  pseudo-membrane  used  by 
the  atomizer  or  gargle,  preferably  by  the  former,  or  one  of  the  following 
mixtures  may  be  employed  : 

No.  1. 

R. — Acid,  carbolic.       .......      zss. 

Aqute  calcis.  .......      ^viij. — Misce. 

No.  2. 

R. — Acid,  carbolic '     .         .  ^.=5. 

Potas   chlorat.       ,         .         ,         .         .         .         .  ziij. 

Glycorin;e      .         ,         .         .         .         .         .         .  5ij. 

Aqute 3vj. — Misce. 

More  recent  investigations,  conducted  by  Dr.  Chadbourne,  have 
shown  that  liquor  pota.ssfE,  or  liquor  sodoe,  one  part  to  forty  of  water, 
is  a  still  more  active  solvent  of  fibrin.  For  further  particulars  relating 
to  these  investigations  the  reader  is  referred  to  our  remarks  on  the 
treatment  of  pseudo-membranous  laryngitis. 

Employ  atomiz.er  every  hour  or  second  hour.  India-rubl)er  tubin<T, 
which  does  not  interfere  Avith  the  action,  should  l)e  drawn  over  the  sharp 
point  of  Delano's  atomizer.  In  this  connection,  I  Avould  state  that  the 
hand  atomizer  with  double  bulb  is  preferable  to  that  with  single  bulb, 
as  the  child  tolerates  better  the  steady  spray.  The  advantage  of  its  use 
is  very  notable  in  the  treatment  of  diphtheritic  croup. 

In  most  cases  of  diphtheritic  inflammation  of  the  fauces  the  spray 
suffices  for  local  treatment,  but  the  following  mixture,  applied  by  a 
large  camel's-hair  pencil,  is  also  very  effectual,  immediately  converting 
the  pseudo-membrane  into  an  inert  mass,  and  putting  a  stop  to  all 
movements  of  the  bacteria  which  swarm  in  it,  as  I  have  observed  under 
the  microscope : 

R. — Acid,  carbolic ptt.  viij. 

Liq.  fcrri  8ub.siil[)hat .5'.i-''.i- 

Glycerinie 3j'. — iMisce. 

This  may  be  used  two  or  three  times  daily,  between  the  spraying,  or 
oftener  without  the  spraying.  It  is  not  irritating  (such  an  effect  would 
condemn  it),  but  it  is  dreaded  by  most  children,  on  account  of  the 
unplea.sant  "puckering"  which  it  ])roduces,  and  the  pain  from  the 
contraction,  Avhich  sometimes  extends  to  the  ear. 

That  form  of  diphtheritic  inllaiiimation  which  most  imperatively 
recjiiires  local  treatment,  and  in  which  local  measures  are  of  more 
imfiortance  than  the  constitutional,  is  obviously  the  laryngeal.  Catar- 
rhal laryngitis  sometimes  occurs  in  dij)hthcria,  as  I  have  occasionally 


324  DIPHTHERIA. 

observed  in  the  dead-house,  without  producing  any  marked  symptoms, 
but  the  pseudo-membranous  hiryngitis  of  diphtheria  is  also  common, 
and,  as  all  know,  is  one  of  the  most  dangerous  forms  of  disease.  It  is 
treated  of  elsewhere  in  this  volume. 

Diphtheritic  paralysis  requires  the  use  of  strychnine  Avith  tonics.  I 
ordinarily  employ  the  elix.  phosphat.  ferri  qui.  et  strychnia  of  the 
shops.  Each  drachm  of  this  contains  gr.  -^^  of  strychnia,  and  by  dilu- 
tion with  water  the  proper  dose  can  be  administered  to  a  child  of  any 
age.  Thus,  recently,  a  child  aged  six  years,  having  paralysis  of  tlie 
muscles  of  the  pharynx,  recovered  in  about  one  week,  by  the  use  of 
one  drachm  of  this  medicine  daily,  given  in  four  or  five  doses.  I  have 
not  found  it  necessary,  in  any  case  which  I  have  observed,  to  employ 
electricity,  but  it  is  no  doubt  useful  in  expediting  recovery,  especially 
if  the  paralysis  be  in  the  limbs.  The  an?emic  state  which  succeeds 
diphtheria  requires  the  use  of  iron  for  several  weeks  in  the  paralytic  as 
well  as  non-paralytic  cases. 

For  the  treatment  of  nasal  diphtheria,  a  mixture  like  the  following 
should  be  injected  warm  into  each  nostril  every  two  to  four  hours : 

U. — Aoidi  horacic.  .......     ^ij. 

Sudii  chloridi  .......     ^j. 

Aqujc     .........     Uj. — Misce. 

Warm  lime-water  may  also  be  used  for  this  purpose. 

Preventive  Measures. — The  occurrence  of  diphtheria  in  a  family 
necessitates  the  prompt  removal  of  other  children  of  the  family  either 
out  of  the  house  or  to  a  distant  part  of  it,  and  the  disinfection  of  the 
room,  and  the  handkerchiefs,  and  other  linen,  and  spittoons  employed. 
The  diphtheritic,  like  the  scarlatinous,  virus  may  remain  for  weeks  or 
months  in  a  locality  or  apartment.  In  East  Fifty-fifth  Street  two 
families  resided  in  a  brown-stone  house,  the  sanitary  condition  of  which 
was  apparently  good.  In  December,  1<S74,  diphtheria  occurred  in  one 
of  these  families,  who  occupied  the  lower  floor  and  the  basement,  causing 
the  death  of  two  of  the  cliildren.  The  other  family,  in  order  to  escape 
the  danger,  immediately  removed  to  another  part  of  the  city,  where 
they  remained  two  months,  returning  liome  on  March  Gth.  On  March 
14th  and  15th,  eight  and  nine  days  after  the  return,  their  two  children, 
aged  5J  and  4^  years,  Avho  had  been  allowed  free  access  to  the  room  in 
which  the  fiital  cases  had  occurred,  also  took  severe  diphtheria,  one  of 
them  dying. 

In  another  family,  living  in  the  suburbs  of  New  York,  a  lady  con- 
tracted diphtheria  from  her  brother's  child,  who  died  of  the  malady  a 
few  blocks  distant.  Returning  home,  she  occupied  a  small  room,  re- 
maining constantly  in  it,  and  by  prompt  treatment  was  soon  con- 
valescent. Her  only  child,  a  boy  of  six  years,  was  excluded  from  her 
companionship  about  one  month,  after  which  he  was  allowed  to  enter 
the  room,  and  slept  in  it.  AVithin  a  few  days,  namely,  thirty-five  days 
after  it  commenced  in  the  mother,  the  diphtheritic  patch  appeared  upon 
his  fauces.  In  one  of  the  asylums  of  this  city,  diphtheria  has  been  pre- 
vailing more  than  a  year,  the  cases  occurring  mainly  in  one  of  the 
buildings,  and  with  so  little  break  or  intermission  that  it  appears  that 
the  diphtheritic  virus  has  not  been  eradicated  from  one  or  more  of  the 


PERTUSSIS.  825 

wards  since  the  first  case  occurred.  Sucli  instances  show  the  danger 
of  admitting  chihh-en  into  rooms  where  diphtlieria  has  occurred,  until 
a  considerable  period  has  elapsed,  and  thorough  disinfection  has  been 
employed. 

When  diphtheria  is  prevalent,  indisposition  on  the  part  of  a  child, 
and  especially  febrile  symptoms,  or  delluxion  from  the  nostrils,  should 
at  once  arrest  attention.  Although  there  be  no  complaint  of  soreness 
of  the  throat,  the  fauces  should  be  carefully  inspected,  and  if  they  seem 
too  red,  they  should  be  sprayed  with  one  of  the  mixtures  recommended 
above. 

Pertussis. 

Pertussis  is  an  infectious  disease  attended  and  manifested  by  a 
catarrh  of  the  air-passages.  This  catarrh  gives  rise  to  a  cough  which 
does  not  differ,  during  the  inception  and  in  the  declining  period,  from 
that  in  an  ordinary  catarrh,  but  during  the  middle  period  of  the  malady 
is  spasmodic.  Exceptionally  the  system  is  so  mildly  affected  that  the 
spasmodic  element  of  the  cough  is  lacking  through  the  whole  course  of 
the  malady,  or  is  confined  to  a  brief  period.  This  distinctive  symptom, 
namely,  the  peculiar  cough,  has  been  attributed  to  the  irritating  and 
disturbing  action  of  the  specific  principle  on  the  nerves  Avliich  control 
the  muscles  of  respiration.  Some  attribute  it  to  the  impression  pro- 
duced upon  the  filaments  of  the  pneumogastric,  especially  upon  those 
of  the  internal  branch  of  the  superior  laryngeal  nerve,  by  the  mucus 
which  collects  in  the  larynx  and  trachea,  and  which  is  known  to  con- 
tain the  contagious  principle  in  abundance.  This  cough  consists  in  a 
series  of  forciltle  and  loud  expirations,  followed  by  a  noisy  and  difficult 
inspiration.  Its  special  character  is  due  to  spasmodic  contraction  of 
the  muscles  of  expiration,  and  notably  of  the  small  muscles  of  the  larynx 
so  as  to  produce  narrowing  or  even  closure  of  the  a])erture  of  the  glottis. 
Each  paroxysm  of  tlie  cdu'jIi  usually  ends,  not  always,  in  the  expecto- 
ration of  viscid  mucus.  With  rare  exceptions  pertussis  affects  the  same 
individual  but  once.  Rilliet  and  Barthez  report  a  case  of  its  second 
occurrence,  and  We^t  another  case.  I  have  iittended  two  adult 
patients,  both  wonun  of  intelligence,  who  stated  that  they  had  had 
previous  attacks  in  early  life.  Pertussis  usually  jn-evails  as  an  ei)i- 
deinic,  but  is  o:;'.'asionally  sporadic,  at  which  time  its  type  is  mild.  It 
is  highly  contagious  thi'oiigh  the  breath  of  the  patient,  or  from  exhala- 
tions from  his  surface. 

In  one  instance  I  was  able  to  ascertain  accurately  the  incubative 
period  of  pertussis.  ]Mrs.  B.,  having  a  cough  for  two  weeks,  which  was 
afterwards  ascertained  to  be  that  of  pertussis,  came  fi  jm  Hoston  to  a 
family  in  New  York.  She  remained  with  this  family  from  '2  P.  M., 
January  2,  1.S7U,  till  the  eveniiiii;,  when  she  left  the  city.  During  her 
stiiy  she  held  and  kissed  an  infant  that  was  previously  well,  and  h:id 
never  been  removeil  from  the  fioor  on  which  it  was  l»orn.  Pertussis 
was  not  at  that  time  prevailing  in  New  York.  On  ihe  titli,  or  four 
days  after  exposure,  the  infant  began  to  cough,  ami  this  [>roved  to  bo 
the  beginning  of  a  severe  pertussis. 


326  PERTUSSIS. 

Age. — Most  cases  of  pertussis  are  betAveen  the  ages  of  one  year  and 
eight  years,  but  it  occasionally  occurs  in  adults  and  even  old  people 
who  have  not  been  attacked  previously.  It  is  rare  under  the  age  of 
three  months,  but  through  the  kindness  of  Dr.  Ewing,  of  New  York,  I 
was  enabled  to  see  a  newborn  infant  Avith  pertussis,  whose  motlier  had 
had  the  disease  during  the  two  months  preceding  her  confinement. 
This  infant  when  fifteen  minutes  old,  and  during  the  washing,  had  the 
first  convulsive  seizure,  which  appeared  to  consist  chiefly  of  a  spasm  of 
the  lai'yngeal  muscles,  with  temporary  suspension  of  the  respiration, 
and  attended  by  deep  lividity  of  the  features,  with  some  frothing  from 
the  mouth.  These  attacks  occurred  nearly  every  hour,  with  intervals 
of  complete  cessation  of  symptoms.  The  mucus  between  the  lips 
finally  became  stained  Avith  blood,  and  death  occurred  on  the  third  day. 
The  mother,  the  intelligent  wife  of  a  clergyman,  believes  that  the  infant 
had  similar  attacks  before  its  birth,  for  she  frequently  experienced  in 
the  last  weeks  of  gestation  Avliat  seemed  to  be  strong  convulsive  move- 
ments in  the  fetus,  the  duration  of  Avhich  corresponded  with  that  of  the 
attacks  in  the  infant.  A  similar  case  is  related  by  liilliet  and  Barthez,' 
and  another  by  Keating.^  These  cases  throw  light  on  the  pathology  of 
pertussis,  for  they  show  that  the  specific  principle  resides  in  the  blood, 
and  that  this  disease  is  therefore  general  or  constitutional,  and  is  not 
localized  on  the  respiratory  surfaces  us  some  have  held  ;  or  if  the  specific 
principle  resides  in  or  upon  the  laryngo-tracheal  surface,  it  must,  in 
some  eases,  if  not  in  all,  infect  the  blood,  else  it  could  not  be  contracted 
in  the  t'mV.d  state. 

Causes. — Climate,  race,  and  nationality  do  not  seem  to  exert  any 
decided  influence  on  the  spread  of  pertussis.  Females  are  somewhat 
more  liable  to  be  attacked  than  males,  and,  as  we  have  seen,  a  large 
maj  ority  of  the  cases  occur  betAveen  the  ages  of  one  and  ten  years.  Letze- 
rich,  about  the  year  1870,  supposed  that  he  had  discovered  the  cause  of 
pertussis  in  a  fungus,  Avhich,  received  upon  the  surface  of  the  air-passages 
in  inspiration,  increases  rapidly  and  produces  the  spasmodic  cough  by 
its  irritating  action,  or  the  irritating  property  which  it  imparts  to  the 
mucus.  In  the  first  stage  of  pertussis  he  found  only  the  spores  of  the 
fiingus,  and  at  a  more  advanced  stage  in  addition  to  tlie  spores,  he  dis- 
covered branches  of  the  thallus.  He  })laced  mucus  holding  the  cryp- 
togam upon  the  fauces  of  the  rabbit,  and  Avitnessed  the  production  of 
pertussis  in  this  animal.  Recently  Burger,^  of  Bonn,  states,  "that  the 
microorganism  of  pertussis  is  visible  Avith  a  power  of  340  to  600  diam- 
eters, appearing  as  little  rods  of  unequal  size.  With  a  higher  power  it 
is  seen  tbat  the  rods  have  tlie  biscuit  fi)rm.  The  groups  of  bacteria  are 
irregularly  disseminated  or  disposed  in  line,  and  somcAvhat  resemble  the 
leptothrix  buccalis.  The  method  of  ])rei)aration  is  very  simple.  A 
small  quantity  of  the  expectoration  is  pressed  betAveen  tAvo  cover  glasses, 
exposed  to  the  flame  of  a  Bunsen  burner  to  coagulate  the  albumen ;  the 
coloring  matter  is  then  added  (watery  solution  of  fuchsin,  or  of 
methyl  violet);  it  is  then  Avashed  thoroughly  in  Avater,  or  the  coloring 

'  Treatise  on  llio  Diseases  of  Children. 

*  Syslcin  of  Medicine  by  American  Authors;   Lea  Bros.,  Pliiladel|ihia,  1885. 

'  Berlin,  klin.  Wochenschrift ;  London  Medical  Record,  May  15,  1884. 


PATHOLOGICAL    AXATGMY.  327 

matter  removed  by  Avashing  in  alcohol,  the  bacteria  alone  remaining 
colored.  These  bacilli  are  not  found  in  any  other  expectoration ;  they 
are  so  abundant,  that  it  is  difficult  to  contest  their  action,  their  fre- 
quency is  always  in  direct  relation  with  the  intensity  of  the  disease." 
Dr.  Poulet^  also  confirms  the  statement  of  a  special  microorganism  in 
pertussis,  from  his  examinations.  But  no  one  has  yet  employed  the  test 
of  Pasteur  with  the  supposed  pertussis  microbe,  to  wit,  cultivation.  We 
will  accept  as  certain,  the  discovery  of  this  microbe,  if  it  have  passed 
through  a  series  of  cultivations,  and  the  disease  be  reproduced  with  the 
last  product  either  in  man  or  in  some  animal  as  the  rabbit. 

Lesions  have  been  discovered  in  certain  fatal  cases  wliich  have  been 
supposed  to  throw  light  on  the  etiology  of  pertussis,  but  which  are  now 
known  to  have  been  merely  coincidences  or  results  of  the  disease.  Such 
are  congestion  of  the  spinal  cord  and  its  meninges,  hypei'remia  of  the 
pneumogastrics,  and  tumefiction  of  the  tracheo-bronchial  glands,  which 
it  was  claimed  produced  the  spasmodic  cough  by  compressing  the  recur- 
rent laryngeal  nerve. 

Patiiological  Anatomy. — Catarrhal  inflammation  of  the  air-passages 
is  uniformly  present.  It  occasionally  occurs  on  the  mucous  surface  of 
the  nostrils  and  pharynx,  but  is  often  absent  from  these  parts.  In  the 
majority  of  patients  the  inflammation  affects  the  surface  of  the  glottis  and 
that  below  the  glottis.  However,  in  not  a  few  cases  the  surface  of  tlie 
larynx  and  trachea  is  pale  and  not  swollen,  or  the  inflammatory  appear- 
ance is  limited  to  a  small  part,  as  the  ventricles  of  the  larynx,  Avhile  the 
mucous  coat  of  the  bronchi  and  their  branches  is  swollen  and  red,  and 
covered  with  tenacious  mucus.  Sometimes  certain  alveoli  are  found 
distended  by  a  tliick  muco-pus,  producing  an  appearance  like  minute 
tubercles. 

A  common  lesion  found  in  the  lungs  of  those  who  have  perished  with 
this  malady  is  emphysema,  affecting  chiefly  the  peripheral  portions  of 
the  upper  lobes.  It  is  usually  vesicular  em]!hysema  occurring  from 
over-distention  of  the  air-cells,  but  in  some  instances  the  air  has  cs -aped 
into  the  connective  tissue,  causing  interstitial  emphysema.  According 
to  my  recollection  of  fatal  cases,  wliich  have  occurred  from  time  to  time 
in  the  institutions  of  New  York,  and  in  which  I  have  made  post-mortem 
examinations,  the  upper  lobes  were  exsanguine  and  inflated  to  lu-arly 
the  fullest  extent  possible  within  the  thorax,  while  other  portions  of  the 
lungs  presented  areas  of  pneumonic,  or  more  or  less  comph'te  atelectatic 
solidification.  Pneumonia,  atelectasis,  and  small  extravasations  of  l)lood 
in  the  lungs,  are,  indeed,  common  lesions.  Hyperplasia  of  the  bronchial 
glands  is  also  common,  and  hyperplasia  has  also  been  occasionally  ob- 
served of  other  lymphatic  glands,  as  tlie  mesenteric.  An  ulcer  under 
the  tongue  wliich  observers  liave  fre<|uently  noticed  is  now  attributed  to 
pressure  of  the  tongue  on  the  lower  incisors  during  the  cough. 

In  fatal  cases,  small  extravasations  of  blood  in  or  upon  tlic  luaiii  arc 
common,  as  is  also  passive  congestion  of  the  sinuses,  veins,  and  capilla- 
ries, meningeal  and  cerebral,  attended  with  more  or  less  transudation  of 
serum  within  the  ventricles  of  the  brain,  and  between  the  meninges. 

*  Le  Scalpel;  London  Medical  Kocord,  ^luy  Lj,  1884 


328  PERTUSSIS. 

Large  dark  and  soft  clots,  and  .occasionally  some  that  are  white  or  yellow, 
are  common  in  the  iutra-cranial  siimses,  especially  if,  as  often  happens., 
death  have  occurred  in  convulsions,  which  supervened  upon  the  severt^ 
spasmodic  cough. 

Symptoms. — Pertussis  consists  of  three  stages:  first,  that  of  catarrh 
of  the  air-passages ;  secondly,  the  stage  of  spasmodic  cough,  or,  for 
brevity,  the  spasmodic  stage ;  thirdly,  the  stage  of  decline. 

The  first  period  is  characterized  by  the  symptoms  of  coryza  and  bron- 
chitis, which  present  nothing  peculiar  or  different  from  ordinary  catarrh 
of  the  same  parts,  unless  occasionally  the  cough  be  more  frequent  and 
teasing.  Trousseau  has  known  it  to  be  repeated  forty. or  fifty  times  per 
minute.  The  eyes  present  a  moderately  suffused  apj)earance,  and  there 
is  sneezing,  with  detluxion  from  the  nostrils,  but  less  than  in  the  com- 
mencement of  measles.  The  cough,  which  commences  as  soon  as  the 
catarrh  affects  the  larynx,  is  accompanied  by  little  or  no  expectoration. 
The  pulse  and  respiration  are  moderately  accelerated,  and  such  other 
symptoms  as  commonly  accompany  catarrh  of  a  mild  grade  are  present, 
namely,  increased  heat  of  surface,  thirst,  and  impaired  appetite. 

The  duration  of  the  first  stage  varies  in  different  cases.  In  severe 
hooping-couglTit  may  last  only  two  or  three_days,  and  in  mild  cases  be 
protracted  to  Jive  or  six_w;eeks.  It  may  be  absent  especially  in  very 
young  infants.  We  have  alluded  above  to  the  newborn  infiint,  in  whom 
there  Avas  no  first  stage,  a  glottic  S})asm  occurring  soon  after  birth.  The 
first_stage  commonly  ends  in_froin  eiglJ[t.4Q,,f^"teen^days.  In  fifty-five 
cases  observed^  by  Dr.  IVest  its  average  duration  was  twelve  days  and  "/< 
seven-tenths  of  a  day.  It  is  stated  above  that  the  first  stage  in  rare 
instances  continues  during  the  entire  course  of  pertussis ;  at  least  no 
spasmodic  cough  occurs.  In  two  such  cases  which  I  now  recall  to  mind, 
both  girls,  the  inflammatory  symptoms  abated  somewhat  after  the  first 
few  days,  and  an  occasional  easy  cough  remained,  like  that  of  simple 
bronchitis,  and  it  continued  during  a  period  corresponding  with  the 
ordinary  duration  of  pertussis.  The  diagnosis  would  have  been  doubtful, 
except  for  the  occurrence  of  pertussis,  with  its  regular  stages,  in  other 
children  of  the  same  families. 

Second  Period. — This  may  commence  quite  abruptly,  but  ordinarily 
its  beginning  is  gradual.  While  the  cough  commonly  has  the  character 
present  in  the  first  stage,  it  is  now  and  then  observed  to  be  more  severe 
and  spasmodic,  especially  at  night,  and  when  the  patient  is  in  any  way 
excited.  The  spasmodic  element  increases,  so  that  in  the  course  of  a 
week  all  doubt  as  to  the  nature  of  the  disease  is  removed. 

The  severity  of  the  cough  in  the  second  stage  varies  considerably  in 
different  cases.  It  sometimes  commences  quite  abruptly,  w'th  little 
Avarning,  but  commonly  there  is  premonition  of  it,  and  the  child  endeav- 
ors to  repress  it.  He  experiences  a  tickling  sensation  in  the  throat,  or 
median  line  of  the  chest,  or  a  feeling  of  constriction.  Tie  leaves  his 
j)laythings,  and  rests  his  head  on  his  mother's  lap,  or  takes  hold  of  some 
firm  object  for  support;  his  face  has  a  grave  or  even  anxious  appear- 
ance, Avliile  the  jmlse  and  respiration  are  somewhat  accelerated.  Imme- 
diately the  cough  begins.  It  consists  in  a  series  of  short  and  hurried 
expirations,  which  expel  a  large  ])art  of  the  air  contained  in  the  lungs, 


SYMPTOMS.  329 

followed  by  a  hurried  inspiration,  which  is  difficult  and  noisy  on  account 
of  the  spasmodic  contraction  of  the  laryngeal  muscles,  and  narrowing 
of  the  glottic  aperture.  The  sound  which  accompanies  the  inspiration, 
and  which  is  often  absent,  especially  in  inflxnts  is  designated  the  hoop. 
The  forcible  expirations,  and  difficulty  experienced  in  expelling  the 
air  from  the  lungs  on  account  of  the  constriction  of  the  glottis,  afford 
exphmation  of  the  emphysematous  distention  of  the  air-cells  in  the 
upper  lobes,  which  Ave  have  seen  is  so  common  in  severe  pertussis. 

There  may  be  a  single  series  of  expirations  terminating  in  the  man- 
ner stated,  but  often  there  are  several  such  series  embraced  in  a  par- 
oxysm. The  cough  commonly  ends  in  the  expulsion  of  frothy  mucus 
from  the  bronchial  tubes,  and  sometimes  in  vomiting.  During  the 
cough  there  is  temporary  arrest  of  blood  in  the  lungs,  leading  to  con- 
gestion in  the  right  cavities  of  the  heart,  and  throughout  the  systemic 
circulation  ;  therefore  tlie  face  is  flushed  and  swollen,  and  occasionally 
hemorrhage  occurs  under  the  conjunctiva,  or  from  one  of  the  mucous 
surfaces.  The  most  frequent  hemorrhage  ^is  epistaxis.  When  the 
cougli  ceases,  the  normal  respiration  is  restored,  tlie  fulness  of  the 
vessels  immediately  abates ;  but  often  puffiness  of  the  features  is  ob- 
served, due  to  serous  infiltration  of  the  sul)cutaneous  connective  tissue, 
and  continuing  for  days  or  weeks  during  the  period  when  the  cough  is 
most  severe.  The  paroxysm  lasts  from  a- quarter  to  a  half  or  even  a 
whole  minute,  and  in  that  time,  in  cases  of  ordinary  severity,  there  are 
often  as  many  as  fifteen  or  twenty  series  of  expirations. 

At  the  close  of  the  paroxysm,  if  there  be  no  complication,  the  symp- 
toms soon  abate ;  the  temperature,  pulse,  and  respiration  become  normal, 
and  there  is  no  evidence  of  disease.  The  cough  in  the  second  stage  is 
much  more  fre(iucnt  in  one  case  than  another.  At  tlie  height  of  this 
stage  it  is  generally  more  severe  if  it  occur  at  long  intervals  than  when 
frequent.  During  the  weeks  in  which  pertussis  is  most  severe,  there  is,  JjJo, 
in  the  average,  about  one  paroxysm  of  coughing  in  each  hour.  ~ 

The  cougli  i|icii,;ascs_jn  severity  till  the  thjrd_jm}]ij)fjJlil_jiac^ 
stage,  or  the  thirtieth  to  thirty-fifth  day  of  the  disease,  after  which  it  'X^^ 
reuiains  stationary  for  a  certani  time.  It  is  apt  to  be  more  frequent  in 
the  night  than  daytime.  Sometimes  it  occurs  while  the  child  is  quiet; 
it  may  even  awaken  him  from  sleep,  but  it  is  often  also  produced  by 
mental  excitement  or  by  physical  exertion.  Anger  or  fright  gives  rise 
to  it,  and  therefare  the  child  is  a|)t  to  cougli  when  being  examined  by 
the  physician,  or  when  his  wishes  are  not  complied  Avith.  The  ordinary 
duratifju  of  the  second  stage  is  from  tlijxly  t'>  sixty  days.  It  may,  how- 
ever, be  considerably  longer  or  shorter  than  this. 

The  third  sfa/e,  which  commences  at  the  time  when  the  spasmodic 
cough  begins  to  abate,  is  short,  not  continuing  longer  than  two  or  three 
weeks.  A  ])rotracted  stage  of  decline  indicates  some  complication. 
While  the  sputum  in  the  second  stage  is  mucous  and  frothy,  that  in  the 
third  stage  is  more  opa(pie  and  ])uriform. 

In  the  third  as  in  the  second  stage,  if  there  be  no  complication,  the 
pulse  and  respiration  in  the  intervals  of  the  paroxysms  are  nearly  or 
quite  natural.  Febrile  excitement,  may,  however,  now  and  then  occnr 
from  trifling  causes,  or,  indeed,  without  any  apparent  cause.  The 
digestion  and  the  general  health  in  uncomplicated  pertussis  remain  ur- 


330  PERTUSSIS. 

impaired,  with  the  exception  of  more  or  loss  emaciation,  which  is  apt  to 
occur  in  all  but  the  mildest  cases,  in  consequence  of  the  frequent  vomit- 
ing. After  complete  recovery,  it  is  not  unusual  for  the  spasmodic  cough 
to  reappear  at  times,  for  one  or  even  two  years.  The  cough  of  ordinary 
simple  laryngitis,  or  bronchitis,  assumes  this  character. 

Complications. — These,  like  the  symptoms,  are  chiefly  of  a  twofold 
character,  namely,  inflammatory  and  neuropathic.  From  the  nature  of 
the  cough  in  pertussis,  it  would  naturally  be  supposed  that  the  spas- 
modic aftection  which  is  now  designated  internal  convulsions,  and  which 
is  characterized  by  spasm  of  certain  muscles  of  respiration  Avould  be  a 
frequent  complication.  It  does  sometimes  occur  in  young  children,  but 
it  is  not  common.  Clonic  convulsions  affecting  the  external  muscles  are, 
on  the  other  hand,  not  infrequent.  They  occur  chiefly  in  the  second 
stage,  when  the  cough  is  most  severe,  and  in  infancy  much  more  fre- 
quently than  in  childhood.  They  are  aj)t  to  be  general  and  severe,  or 
if  not  of  this  character  at  first,  to  become  such.  The  convulsions  com- 
mence, in  most  instances,  in  or  directly  after  the  paroxysm  of  coughing; 
but  they  sometimes  occur  in  the  interval  when  the  child  is  quiet. 

Rilliet  and  Barthez  remark:  "Almost  all  infants  succumb  to  this 
complication,  ordinarily  in  the  twenty-four  hours  which  follow  the  first 
attack ;  nevertheless,  life  may  be  prolonged  during  two  or  three  days." 
(Article  Coqucluche.)  In  my  own  practice  this  complication  usually 
ended  fatally  before  bromide  of  potassium  and  chloral  were  employed, 
but  Avith  the  proper  use  of  these  agents  it  can  often  be  arrested.  In 
the  month  of  June,  1857,  I  was  attending  a  little  girl  two  years  and 
four  months  old,  who  had  reached  the  fifth  week  of  pertussis,  when  she 
was  seized  with  general  clonic  convulsions.  The  mother,  who  was  re- 
quested to  keep  a  record  of  the  number  of  convulsions,  stated  that  there 
were  twenty  in  all,  occurring  within  forty-eight  hours.  They  affected 
both  sides,  the  shortest  lasting  only  three  or  four  minutes,  the  longest 
seventy-five  minutes.  The  treatment  in  this  case,  which  eventuated 
favorably,  will  bo  noticed  hereafter. 

In  those  who  die  of  convulsions  occurring  in  hooping-cough,  the  most 
constant  lesion  is  congestion  of  the  cerebral  veins  and  sinuses,  often  with 
transudation  of  serum.  This  congestion  is  due  in  part  to  the  cough  which 
precedes  the  convulsions  and  in  part  to  the  convulsions  themselves. 
At  the  autopsies  which  I  have  made  of  two  infants,  who  died  in  hos- 
pital practice  from  hooping-cough,  accomi)anied  by  convulsions,  all  the 
cerebral  sinuses  wore  filled  with  clots,  which  were  generally  soft  and 
dark ;  but  in  the  lateral  sinuses  clots  were  found  which  were  light- 
colored.  The  light  color  of  a  clot,  cither  in  a  vein  or  sinus,  indicates 
its  ante-mortem  formation. 

The  gravity  of  the  convulsive  attack  can  bo  ascertained  by  observing 
whether  the  patient  readily  recovers  consciousness.  Its  return  indi- 
cates that  there  is  no  serious  congestion.  On  the  other  hand,  great 
drowsiness  remaining,  or  a  semi-comatose  state,  indicates  persistent 
congestion,  and,  perhaps,  even  the  formation  of  clots  in  the  sinuses  of 
the  brain.  Death  from  convulsions  is  usually  preceded  by  coma. 
Occasionally  meningeal  apoplexy  supervenes  upon  the  congestion,  and 
death  is  innnediate. 

The  most  frei^uent  inflammatory  complications   are  bronchitis  and 


COMPLICATIONS.  331 

pneumonitis.  Inflammation  of  tlie  bronchial  tubes  of  a  mild  grade,  we 
have  seen,  is  a  common  accompaniment  of  pertussis,  but  when  it 
extends  to  the  minuter  tubes,  or  becomes  so  severe  as  to  cause  accele- 
ration of  respiration,  it  is,  properly,  a  complication.  Both  bronchitis 
and  pneumonitis,  occurring  as  complications,  are  developed,  with  few 
exceptions,  in  the  second  stage.  Bronchitis  is  accompanied  by  accele- 
rated respiration  and  pulse,  and  increased  temperature.  The  danger 
is  proportionate  to  the  amount  of  dyspnoea. 

Pneumonitis  is  a  less  common  complication  than  bronchitis,  but  it 
occurs  more  frequently  in  pertussis  than  in  any  other  constitutional 
malady  of  eai'ly  life,  excepting  measles.  The  congestion  which  results 
and  remains  in  the  lung  when  the  cough  is  fi'equent  and  severe,  favors 
the  development  of  pneumonia.  The  symptoms  and  physical  signs 
which  accompany  tliis  inflammation  and  serve  for  its  diagnosis  are  the 
same  as  in  the  primary  form  of  the  disease,  and  are  described  else- 
where. Bronchitis  or  pneumonia  usually  moderates  the  severity  of 
the  spasmodic  cough,  for  when  the  inflammatory  element  in  pertussis 
increases,  the  spasmodic  abates.  On  the  abatement  of  the  inflamma- 
tion, however,  tlie  cough  usually  regains  its  former  convulsive  character. 
The  fact  may  be  stated  in  this  connection,  that  any  complication  or 
intercurrent  disease  which  is  attended  by  decided  febrile  reaction, 
ordinarily  renders  the  cough  for  the  time  less  spasmodic. 

The  occurrence  of  bronchitis  or  pneumonia  is  shown  by  the  elevated 
temperature,  acceleration  of  pulse  and  respiration,  short  and  frequent 
cough.  These  symptoms  do  not  cease  so  long  as  the  inflannnation  con- 
tinues, whcrea.s  in  uncomplicated  pertussis  the  patient  seems  nearly  or 
quite  well  between  the  coughs.  In  pneumonia  the  respiration  is  accom- 
panied by  the  expiratory  moan,  and  in  both  bronchitis  and  pneumonia 
there  is  more  or  less  depression  of  the  infra-mammary  region  during 
inspiration.  These  symptoms,  in  connection  with  the  physical  signs, 
render  diagnosis  in  most  instances  easy.  Although  the  general  char- 
acter of  the  coui^h  is  chani«;ed.  a  cousjh  now  and  then  occurs,  even  when 
the  inflammation  is  pretty  severe,  sufliciently  spasmodic  to  indicate  the 
nature  of  the  primary  aliection.  Capillary  bronchitis  and  pneumonia 
are  always  serious  complications. 

Not  only  is  more  or  less  emphysema  a  common  complication  of 
severe  ])ertiissis,  but  bronchiectasis  also  occurs  in  certain  cases,  due  to 
the  same  conditions.  Empliysema  is  a  common  lesion  in  young  and 
feeble  infants,  even  Avhen  there  is  no  history  of  any  })revious  severe  dis- 
ease of  the  respiratory  organs.  I  have  found  it  one  of  the  most  com- 
mon lesions  in  infants  of  feeble  constitutions,  who  die  in  the  hospitals 
and  asylums  of  New  York,  but  it  is  usually  interstitial  and  confined 
to  a  small  part  of  the  uj)per  lobes.  It  is  not  accompanieil  by  that 
general  distention  of  the  alveoli  and  consc(pient  enlargement  of  the 
lobes  which  occnr  in  the  emphysema  of  j>ertussis.  Its  chief  cause  in 
these  feeble  and  wasted  infants  appears  to  be  im))aired  nutrition  and 
change  in  the  molecular  condition  of  the  pulmonary  tissue.  The  same 
condition  often  occurs  in  severe  and  [)rotracted  ])ertussis,  and  therefore 
serves  as  an  additional  and  efficient  cause  of  the  emphysenia. 

The  following  was  a  not  unusual  case  of  tliis  disease  as  it  occurs  in 
the  tenement  houses  and  asylums  of  New  York.     At  the  meeting  of 


332  PERTUSSIS. 

the  New  York  Pathological  Society,  October  14,  1868,  I  exhibited 
emphysematous  lungs,  removed  from  an  infant  who  died  at  the  age  of 
nineteen  months,  at  the  commencement  of  the  fourth  week  of  pertussis. 
Death  occurred  from  thrombosis  in  the  lateral  sinuses  of  the  cranium, 
resultiniT  from  the  severe  spasmodic  cough,  eclampsia,  and  feebleness 
of  the  circulation,  as  the  infant  was  previously  in  a  reduced  state  from 
chronic  entero-colitis.  At  the  autopsy  the  superior  lobes  of  both  lungs 
were  found  exsanguine,  doughy  to  the  feel,  and  enlarged  so  as  to  rise 
above  the  level  of  the  other  lubes.  The  resiliency  and  elasticity  of  the 
lung  tissue  in  these  lobes  were  evidently  greatly  impaired,  and  their 
air-cells  in  a  state  of  over-distention.  The  other  lobes  were  healthy, 
except  that  one  of  them  was  the  seat  of  catarrhal  pneumonia.  In  this 
case  there  had  been  no  disease  affecting  the  respiratory  apparatus,  pre- 
viously to  the  pertussis,  so  that  the  incipient  vesicular  emphysema  was 
referable  to  the  severe  cough  and  impaired  nutrition  of  the  lungs. 

Occasionally  we  meet  cases  of  severe  pertussis  in  which,  Avhile  there 
is  over-distention  of  the  alveoli  of  the  upper  lobes,  collapse  occurs  over 
a  greater  or  less  extent  of  the  lower  lobes.  Collapse,  like  emphysema, 
may  continue  for  weeks  or  months  subsequently  to  pertussis,  and  then 
gradually  disappear,  but  in  the  following  rare  case  in  my  experience  it 
was  perinanent.  John  O'Neil,  aged  5h  years,  Avas  brought  to  the 
Bureau  for  the  Relief  of  the  Out-door  Poor  in  New  York,  in  December, 
1876.  He  lived  in  the  underground  basement  of  a  tenement-house, 
and  was  supported  by  charity,  except  at  intervals,  when  his  father,  Avho 
Avas  dissipated,  could  obtain  work.  At  the  age  of  fifteen  months  he  had 
a  glandular  swelling  on  the  right  side  of  the  neck,  Avhich  suppurated, 
and  three  months  later  one  on  the  opposite  side,  which  also  sujtpurated. 
At  the  age  of  2h  years  he  had  bronchitis,  the  cough  of  which  did  not 
abate  till  two  months  subsequently.  When  near  the  age  of  three  years 
he  had  measles,  and  the  cough  from  this  disease  lasted  three  or  four 
months.  In  the  summer  of  1875,  or  about  one  year  subsequently  to 
the  measles,  he  contracted  pertussis,  Avhich  Avas  severe,  but  Avas  alloAved 
to  run  its  course  Avithout  treatment.  It  lasted  four  months,  never,  hoAV- 
ever,  confining  him  to  bed  or  materially  impairing  his  api)etite.  One 
morning  about  the  close  of  the  seccmd  month  of  the  malady,  the  parents 
filrst  observed  depression  of  the  right  side  of  the  thorax.  This  gradually 
increased  for  a  fcAVAveeks  and  has  been  permanent.  The  parents  stated 
that  he  had  never  been  confined  to  the  house  or  without  appetite  except 
during  the  Aveek  of  measles. 

Since  his  recovery  from  pertussis  he  has  had  his  usual  ap])etite  and 
general  health,  but  crying  or  excitement  connnonly  brings  on  a  pretty 
severe  cough.  The  depression  of  the  thorax  examined  in  front,  begins 
quite  abruptly  in  the  line  of  the  left  costo-chondral  articulations.  Cir- 
cumferential measurement  of  the  left  side  from  the  middle  of  the  sternum 
to  the  spine,  the  tape  lying  a  little  beloAV  the  nipple,  gives  eleven  and  a 
half  inclies,  Avhile  corresjxmding  measurement  of  the  right  side  gives 
seven  and  a  half  inches;  pulse  l-)(),  sounds  of  the  heart  normal ;  respira- 
tion 44.  On  auscultation  over  the  right  side  of  the  chest  Ave  observed 
bronchial  respiration,  and  a  feeble  bronchophony,  Avith  perhaps  slight 
vocal  fremitus.     The  accompanying  figure  is  from  a  photograph  by  Mr. 


DIAGNOSIS. 


333 


Fig.  24. 


Mason,  photographer  to  Bellevue   Hospital.     ]My  first  impression  on 

observing  tliis  case  was  that  it  was  one  of  unexpanded  lung,  which  had 

been  compi-essed  by  a  pleuritic  effusion,  but  it  is  seen  that  the  history 

points  clearly  to  pertussis  as  tlie  cause  of  the 

deformity.     The  depression  occurred  somewhat 

suddenly  when  the  cough  was  most  severe,  and 

when  there  was  no  fever,  loss  of  appetite,  or 

other  symptom  of  pleuritis.     The  patient  had 

not  presented  any  marked  evidence  of  rachitis, 

but  was  decidedly  strumous. 

Pertussis  is  sometimes  complicated  by  the 
eruptive  fevers.  There  does  indeed  seem  to  be 
some  affinity  between  it"  and  measles,  so  that 
many  epidemics  of  the  two  have  been  observed 
at  about  tlie  same  time.  During  my  term  of 
service  in  the  New  York  Foundling  Asylum,  in 
May,  1S78,  measles  and  pertussis  prevailed  jn 
the  wards  at  the  same  time.  Eighteen  of  the 
children,  who  were  having  pertussis,  contracted 
measles,  and  the  Sisters,  who  were  very  intelli- 
gent and  faithful  observers,  and  were  retpicsted 
by  me  to  notice  the  effect  of  tlic  c(jmplication, 
stated  that  with  few  exceptions  the  severity  of 
the  hooping-cough  Avas  increased  during  the  con- 
tinuance of  the  exanthem.  This  is  contrary  to 
the  general  belief  of  the  effects  of  intercurrent 
febrile  diseases. 

Diagnosis. — During  the  period  of  invasion  it  is  impossible  to  diag- 
nosticate pertussis.  Its  nature  can  only  be  conjecturetl  from  a  known 
exposure  or  from  the  epidemic  occurrence  of  the  disease.  In  the  second 
stage,  which  is  characterized  by  the  spasmodic  cough,  diagnosis  is  ordi- 
narily easy,  and  often  the  parents  are  able  to  announce  the  nature  of 
tlic  disease  Avhen  the  physician  is  called.  Still,  a  mistake  is  sometimes 
made;  a  spasmodic  cough  very  similar  to  that  of  pertussis  occasionally 
occurs  in  other  maladies.  Young  infants  with  bronchitis  frequently  ex- 
perience great  difficulty  in  the  expectoration  of  mucus,  which  collects  in 
the  air-passages  and  provokes  a  suffocative  cough.  The  following  facts 
will  iiid  in  n>aking  the  diagnosis.  Bronchitis,  accompanied  by  a  suffo- 
cative cough,  is  an  acute  disease,  and  the  cough  occurs  at  an  early 
period,  usually  in  the  first  week.  It  lacks  the  inspiratory  sound  or  the 
hooj),  and  is  associated  with  constantly  accelerated  respiration  and  well- 
marked  febrile  symptoms,  dependent  on  the  inilammation.  Moreover, 
the  cough  is  occasionally  suffocative,  according  to  the  amount  of  mucus 
in  the  tubes.  The  spasmodic  cough  of  pertussis,  (m  the  other  hand,  is 
j)recedcd  by  the  stage  of  invasion,  arul  it  occurs  only  in  the  second  stnge, 
when  the  febrile  symi)toms  have  abated.  Again,  the  suffocative  cough 
<tf  bronchitis  rarely  ends  in  vomiting,  which  is  common  in  the  cough  of 
pertussis. 

The  only  other  disease  with  which  there  is  mtich  likelihood  of  con- 
founding pertussis  is  bronchial  phthisis.      The  points  of  differential  ding 


334  PERTUSSIS. 

nosis  are  the  following :  the  one  epidemic,  and  spreading  by  contagion ; 
the  other  non-contagious  and  isolated :  the  one  embraced  in  tliree  dis- 
tinct stages,  and  much  shorter;  the  other  chronic,  and  presenting  no 
stages,  but  commencing  with  mild  non-febrile  symptoms,  and  progres- 
sively becoming  more  severe:  in  the  one  an  absence  of  symptoms  in  the 
intervals  of  the  cough,  provided  that  there  be  no  complication;  in  the 
other  constant  symptoms,  such  as  are  common  in  tubercular  disease. 
The  previous  health,  and  tlie  presence  or  absence  of  a  tubercular 
cachexia,  should  be  considered  in  determining  the  nature  of  the  disease. 
Usually,  in  bronchial  phthisis,  the  lungs  are  also  affected,  so  that  auscul- 
tation and  percussion  may  furnish  positive  proofs  of  the  nature  of  the 
cough. 

The  attacks  of  suffocative  cough,  which  are  produced  by  the  lodgement 
of  a  foreign  body  in  the  larynx,  or  lower  down  in  the  air-passages,  bear 
a  close  resemblance  to  those  of  pertussis.  The  diagnosis  can  be  made 
by  the  history,  for  in  the  one  case  there  is  a  preliminary  catarrhal  stage, 
and  in  the  other  the  cough  begins  abruptly,  and  usually  after  the  known 
swallowing  of  the  offending  substance,  which  produces  dyspnoea  and  a 
spasmodic  cough  as  soon  as  it  enters  the  larynx.  The  presence  of  the 
body  can  also  be  determined  in  a  large  proportion  of  cases  by  the  laryn- 
goscope and  auscultation. 

Prognosis. — A  larger  proportion  doubtless  recover  under  the  better 
therapeutics  of  the  present  time  than  in  former  years.  According  to 
Hirsch  (II.,  p.  105)  72,900  persons  perished  from  this  disease  in  Eng- 
land and  Wales  between  1848  and  1855,  or  one  in  every  forty  who 
died;  and  Wilde's  reports  show  that  it  stands  fifth  as  regards  mortality 
among  the  epidemic  diseases  of  Ireland.  In  New  York  City  during 
the  half  century  ending  with  1853,  4840  died  of  pertussis,  or  one  died 
from  this  disease  in  every  76  of  deaths  from  all  causes. 

As  a  rule,  the  older  the  child  the  better  the  prognosis.  Young 
infimts  may  die  of  suffocation  due  to  the  glottic  spasm.  Eclampsia 
with  extreme  passive  congestion  of  the  encephalon  is  a  not  infrequent 
complication  in  children  under  the  age  of  five  years,  and  it  is  ajit  to 
terminate  fatally.  It  may,  however,  in  my  opinion,  be  averted  in  most 
cases  by  proper  treatment.  In  rare  instances  death  may  occur  in  or 
immediately  after  a  paroxysm  of  coughing,  in  consequence  of  rup- 
ture of  cerebral  or  meningeal  capillaries,  and  the  effusion  of  blood,  or 
from  stasis  and  coagulation  of  blood  in  the  venous  system,  especially  if 
convulsions  have  supervened  upon  frecjuent  and  j^rotracted  paroxysms 
of  coughing.  Other  complications,  which  are  likely  to  arise  under  con- 
ditions Avhich  favor  their  develo])ment,  and  which  greatly  increase  the 
danger  and  render  the  prognosis  unfavorable,  are  capillary  bronchitis, 
pneumonia,  diphtheria,  and  in  the  summer  season  intestinal  catarrh. 
In  New  Y^ork  I  have  noticed  that  pertussis  occurring  in  the  summer  is 
much  more  fatal  if  it  become  complicated  with  the  intestinal  catarrh 
which  is  an  epidemic  among  infants  during  that  season. 

Feebleness  of  system  and  antecedent  and  accompanying  chronic  dis- 
ease increase  the  danger.  Pertussis  sometimes  produces  so  much 
emaciation  and  loss  of  strength,  in  consequence  of  the  severity  and 
frequency  of  the  cough,  and  the  repeated  vomiting,  that  intercurrent 


TREATMENT.  335 

diseases  which  in  favoral)le  states  of  the  system  would  probably  end  in 
recovery,  are  very  apt  to  prove  fatal. 

I  usually  inform  the  family  that  the  patient  is  doing  well,  if  he  seem 
entirely  well  between  the  paroxysms  ;  but  if  he  appear  ill,  whether  with 
somnolence,  fretfidness,  fever,  loss  of  appetite,  accelerated  breathing,  or 
diarrhoea,  he  is  not  doing  well,  and  probably  has  some  complication, 
which  requires  immediate  attention.  Sudden  deaths  occur  in  the  second 
stage ;  but  deaths  from  causes  and  conditions  Avhich  operate  in  a  gradual 
and  protracted  manner,  may  occur  in  the  second  or  third  stage. 

Treatment. — In  the  catarrhal  stage  the  treatment  should  be  the 
same  as  in  mild  idiopathic  catarrh.  Demulcent  and  gentle  expectorant 
measures  are  required.  Care  should  be  taken  to  employ  nothing  which 
reduces  the  strength  or  impairs  the  general  health.  If  there  be  much 
bronchitis  with  accelerated  breatliing  and  frequent  cough,  mild  counter- 
irriration  to  the  chest,  and  the  use  of  the  oil-silk  jacket  are  proper. 

Therapeutic  measures  are  chiefly  indicated  in  the  second  stage,  or 
that  of  convulsive  cough.  Proper  treatment  ma}^  control  the  severity 
of  the  cough,  and  abridge  the  duration  of  the  second  stage,  and  prevent 
or  control  complications.  As  with  most  other  diseases  Avliose  cause  and 
nature  are  obscure,  and  which  under  ordinary  circumstances  terminate 
favorably,  pertussis  has  received  a  great  variety  of  treatment.  The 
enumeration  of  the  medicines  and  modes  of  treatment  which  have  had 
their  season  of  repute,  and  been  employed  by  intelligent  physicians, 
would  occupy  too  much  time.  The  treatment  should  vary  in  some 
respects  according  to  the  case,  but  a  small  number  of  medicines  suf- 
fices, even  in  the  most  severe  and  o])stinate  forms  of  the  malady. 
Knowledge  and  appreciation  of  the  pathological  state  in  pertussis  assist 
us  to  the  choice  of  the  proper  remedies.  The  specific  principle  of  per- 
tussis produces  but  little  depression  of  the  vital  powers.  It  does  not 
impair  the  appetite  by  its  direct  action,  or  the  nutritive  function,  nor 
does  it  prodiu-e  those  profound  blood  changes  wliich  we  observe  in  scarlet 
fever  and  diphtheria.  It  atlects  tlie  system  injuriously  by  the  severity 
of  the  cough,  the  vomitings  and  consequent  loss  of  nutriment,  and  the 
complications  which  frequently  occur,  some  of  which  involve  fatal  con- 
seqiu'nces. 

Remedies  are  required  which  diminish  the  sensitiveness  of  thelarvngo- 
traclieal  surface,  which  destroy  the  specific  principle  in  those  ])iirts  where 
the  lo(  al  manifestations  of  tlie  disease  occur,  or  control  its  action — that 
is,  in  the  larynx  and  trachea.  The  use  of  inhalations  is  at  once  sug- 
gested aa  most  likely  to  fulfil  the  indications,  since  by  inhalation  the 
medicine  employed  is  brought  into  immediate  contact  with  the  parts 
which  are  chiefly  concerned  in  the  disease.  In  an  extensive  epidemic 
occurrin''  among  the  lar'^e  numl)er  of  children  in  the  N.  Y.  Foundlinir 
Asylum  a  few  years  since,  after  trial  of  various  agents  for  internal 
treatment,  we  found  that  the  following  mixture  seemed  to  control  the 
disease,  diminishing  the  paroxysmal  cough,  more  effectually  than  the 
other  medicines  employed : 

U  ■ — -Vcidi  carbolic.  .         .......      ^ss. 

Potas.  chlorat., 

Pntas.  brnmidi  .......  Aa   X'}- 

Glycorinai  ........      ^'J- 

Aquae        .........      5vj— Misce. 


336  PERTUSSIS. 

To  be  inlialcd  from  a  steam  atomizer  from  three  to  six  minutes  every 
two  to  six  hours,  according  to  the  severity  of  the  cough.  Since  this 
time,  having  frequently  treated  pertussis,  it  has  seemed  to  me  that  car- 
bolic acid  is  the  efficient  agent  in  the  above  formula,  and  I  now  employ 
it  in  most  cases.  Carbolic  acid  appears  to  have  an  ann;sthetic  effect 
on  the  laryngo-trachcal  surface.  It  is  also  an  efficient  germicide  and 
antiseptic  agent,  so  that,  if  inhaled  frequently,  it  probably  destroys  the 
specific  principle,  so  far  as  it  resides  in  the  mucus  and  epithelial  cells 
of  the  aii--passages.  In  my  practice  it  is  conveniently  employed  in  the 
croup  kettle.  Three  teaspoonfuls  of  the  saturated  solution  of  carbolic 
acid  are  placed  in  water  enough  to  cover  the  bottom  of  the  croup  kettle 
to  the  depth  of  two  inches,  and  when  tliis  is  brought  nearly  to  the  boil- 
ing point  the  vapor  is  inhaled  througli  the  tubes  every  hour  or  second 
hour,  from  three  to  five  minutes.  With  this  treatment  infxnts  a  few 
weeks  old,  as  well  as  those  of  a  more  advanced  age,  have,  with  few  ex- 
ceptions, passed  through  the  disease  without  complications,  and  with 
paroxysms  so  mild  that  the  effect  of  the  treatment  could  not  be  doubted. 
But  the  employment  of  this  agent  with  an  alkali  is  probably  preferable. 
Dr.  Keatinir^  recommends  the  following  formula  for  inhalation  : 

IJ  . — Acidi  carbolici  cryst.         ......      gr.  iij. 

Sodii  biborat., 

Sodii  bicarb.      .......         fui  gr.  xx. 

Glycerine, 

Aqiiie         ........         iia  3J- — Misce. 

An  atmosphere  loaded  Avith  moisture  renders  the  mucus  more  fluid, 
and  the  same  result  may  be  in  a  measure  produced  by  the  inhalation  of 
an  alkali,  as  in  the  above  formula. 

Other  antiseptic  agents  may  be  equally  beneficial  with  the  carbolic 
acid.  Some  of  them,  whose  odor  is  not  so  unpleasant,  have  been  used 
by  good  observers  with  alleged  benefit,  and  recommended  in  the  jour- 
nals.    Paulet^  recommends  the  evaporation,  over  a  suitable  fire,  of 

R  ■ — Spirits  (if  thymol       .......     grammes    10. 

Alcohol     .  ' "         2ri0. 

AVater "         750. 

Keating  also  recommends  the  same  ao;ent  in  the  following  formula : 

R  . — Thymol    .........  gr.  xv. 

jVlcoholis  ........  giij. 

Glycerinse         .         .         .         .         .         .         .         .  5s^;. 

Aquaj        .........  ^xxxiv. — Misce. 

Internal  remedies,  formerly  much  used  now  occupy  the  second 
place  in  the  thera})eutics  of  pertussis.  Belladonna  has  been  largely 
employed,  since  it  appears  to  diminish  the  spasmodic  element  in  the 
cough  of  pertussis.  Brown-Sequard,  in  remarks  made  before  the  United 
States  Medical  Association,  in  May,  1860,  maintained  that  the  dura- 
tion of  pertussis,  so  far  as  its  nervous  element  is  concerned,  might  be 
abridged  to  a  few  days  by  doses  of  atropia  sufficiently  large  to  cause 
toxical  effect;  but  in  one  case,  which  I  saw  in  consultation,  in  which 
one  teaspoonful  of  tincture  of  belladonna  was  given  by  mistake  to  a 

1  Medical  News,  February  28,  1885. 

'  London  Medical  Record,  May  15,  1884. 


TREATMENT.  587 

child  of  abo'it  three  years,  the  subsequent  cough,  though  mild,  did  not 
lose  its  spasmodic  element.  Children  require  a  larger  proportionate 
dose  of  belladonna  than  adults,  and  it  can  be  safely  administered  in 
gradually  increasing  doses  until  physiological  effects  are  produced,  Avhen 
some  mitigation  in  the  cough  may  be  expected.  Probably  the  action 
of  the  drug  is  on  the  respiratory  centres  in  the  medulla  and  not  directly 
on  the  muscles  of  respiration.  The  eifect  of  belladonna  in  controlling 
the  spasmodic  cough  is  most  marked  when  physiological  symptoms  are 
produced,  and  some  children  require  larger  doses  than  others.  Thus  I 
gradually  increased  the  doses  of  belladonna  to  twelve  drops  for  a  child 
of  three  and  a  half  years  who  had  severe  pertussis,  Avithout  producing 
the  characteristic  efflorescence,  Avhile  smaller  doses  from  the  same  bottle 
produced,  this  effect  in  older  children.  Rarelj^  I  have  discontinued  the 
belladonna  on  account  of  diminished  flow  of  urine,  which  this  agent  may 
or  may  not  have  produced,  and  very  rarely  on  account  of  suddenly 
developed  muscular  weakness,  which  I  had  reason  to  think  the  bella- 
donna caused.  This  occurred  in  the  case  alluded  to  above,  in  which 
twelve  drops  of  the  tincture  were  given,  so  that  the  muscles  seemed  flabby, 
and  the  trunk  and  head  were  supported  Avith  difficulty.  The  tincture 
of  belladonna  is  convenient  for  use,  and  most  of  that  in  the  shops  is 
active  and  reliable.  The  doses  which  I  ordinarily  found  to  be  sufficient 
when  prescribing  belladonna  for  pertussis  and  Avhich  also  produced  efflo- 
rescence, Avere  as  f  )llo\vs:  to  a  child  of  two  years  three  drops,  and  to  one 
of  six  or  eight  years,  eight  or  ten  drops,  morning  and  evening.  I 
always,  however,  commenced  Avith  a  smaller  number,  and  continued  to 
administer  the  dose  Avhich  produced  the  local  effects  alluded  to,  unless 
the  cough  Avere  moderated  Avith  smaller  doses.  In  the  majority  of  cases 
I  have  notice<l  no  decided  effect  till  the  rash  was  produced,  Avhcn  the 
svmf)tonis  improved,  the  cough  becoming  less  frequent  or  less  severe. 
I?y  the  belladonna  treatment  the  s})asmodic  stage  may  not  only  be  ren- 
dered mild,  but  abrid<red  to  tAVO  or  three  Aveeks.  In  some  cases  the 
severe  cough  begins  to  yield  almost  immediately  under  full  doses  of  this 
agent,  hut  in  other  cases  its  continuance  for  some  days  is  necessary, 
Avith  other  remedies  as  adjuvants,  before  there  is  any  appreciable  benefit 
from  its  use. 

The  use  of  quinine  as  a  remedy  for  pertussis  Avas  first  strongly  recom- 
mended by]jinz,  Avho  embraced  the  theory  of  Letzerich,  that  this  disease 
is  produced  by  a  fungus,  upon  Avhich  the  quinine  acts  injuriously.  I 
have  not  observed  that  improvement  from  the  use  of  this  agent,  Avhen 
employed  alone — and  it  has  been  largely  ]irescribetl  in  the  institutions 
of  iSew  York — which  I  have  observed  in  cases  treated  at  the  same  time 
Avith  morning  an<l  evening  doses  of  l)ella(lonna.  Its  good  effects  upon 
the  spasmo(lic  cough  arc  probably  due  to  the  fiict  tiiat  it  diminishes 
reflex  irrita])ility  (Schlakow  and  Jlulenl)erg).  At  the  same  time  it  acts 
as  a  tonic,  and  improves  the  appetite,  and  tends  to  prevent  any  depress- 
ing effect  Avhich  might  occur  from  the  belladonna.  It  is  ])eyond  ques- 
tion the  proper  remedy  in  the  fVe(|uent  cases  in  Avhich  febrile  symj)toms 
Arise,  Avhether  from  some  conq)lication  as  bronchitis,  pneumonia,  or  otlier 
causes.  In  ordinary  cases  a  child  of  five  years  rdiould  take  about  two 
grains  four  times  daily,  in  the  elixir  adjuvans  or  other  convenient  vehicle. 


838  PERTUSSIS. 

As  an  antipyretic  a  larger  dose  may  sometimes  be  needed.  In  cases 
attended  by  marked  elevation  of  temperature  antipyrin  may  be  given  in 
three  grain  doses  to  a  child  of  three  to  five  years  every  third  hour,  but 
its  depressing  and  nauseating  effects  in  some  instances  induce  me  to 
prefer  (piinine. 

As  the  paroxysms  are  apt  to  be  more  severe  at  night,  and  the  patient 
conse(j[uently  be  deprived  of  the  required  sleep,  a  medicine  is  indicated 
which  will  procure  some  hours  of  rest,  and  thereby  diminish  the  number 
of  paroxysms.  For  this  purpose  the  hydrate  of  cldoral  is  especially 
useful  given  in  doses  of  two  to  five  grains,  according  to  the  age,  and 
perhaps  repeated.  It  does  not  seem  to  me  that  cliloral  exerts  any 
marked  influence  upon  the  cough;  it  seems  to  be  useful  chiefly  in  the 
manner  stated,  namely,  by  procuring  prolonged  sleep. 

One  of  the  chief  dangers  from  pertussis  we  have  seen  to  be  the  occur- 
rence of  great  passive  congestion  of  organs,  especially  of  the  brain,  with 
the  liability  to  hemorrhages,  serous  efiusion,  and  eclampsia.  This  is  in 
great  part  prevented  by  the  action  of  the  medicines  mentioned  above, 
which  diminish  the  severity  of  the  cough,  or  its  frequency.  But  when 
there  are  great  and  frequent  congestions  of  the  nervous  centres,  produc- 
ing eclampsia  or  premonitions  of  eclampsia,  the  use  of  one  of  the  bromine 
compounds  is  indicated  for  its  prompt  and  decided  action  in  averting  the 
danger.  Even  if  the  symptoms  bo  not  urgent,  its  tranquillizing  effect, 
and  especially  its  prompt  action  in  diminishing  reflex  irritability,  render 
it  one  of  the  most  useful  agents  in  pertussis.  If  there  be  sudden  twitch- 
ing of  the  muscles,  marked  stupor,  headache,  or  fretfulness,  or  adduction 
of  tlie  thumbs  across  the  palms  of  the  hands  during  the  cough,  I  never 
fail  to  give  the  bromide  of  potassium  in  sufficiently  large  and  frequent 
doses,  and  now  eclampsia  occurs  much  more  rarely  in  a  case  which  I 
treat  from  the  commencement,  than  in  former  years. 

The  complications  of  pertussis  require  prompt  treatment.  Whenever 
the  child  feels  ill  between  the  paroxysms,  he  should  be  carefully  exam- 
ineil,  and  some  complication  will  probably  be  found  which  requires 
treatment.  If  the  bronchitis  have  increased  so  as  to  become  a  compli- 
cation, or  pneumonia  have  arisen,  the  whole  chest  should  be  covered  with 
a  light  flaxseed  poultice  containing  one-sixteenth  part  of  mustard,  while 
quinine  and  ammonia  with  alcoholic  stimulants  are  given  at  regular 
intervals.  Cerebral  accidents  are  best  arrested  by  the  warm  foot-bath, 
cold  to  the  head,  and  by  the  bromide  and  chloral. 

Di[)htheria  not  infre(|uontly  supervenes  as  a  complication  in  a  locality 
where  it  is  endemic  or  epidemic,  and  if  mild  it  is  often  overlooked. 
Recently  I  have  seen  a  case  in  which  diphtlieria  complicating  pertussis 
had  continued  four  days,  without  being  recognized  by  the  attending 
physician,  the  symptomg  being  attributed  to  other  causes.  The  diph- 
theritic patch  in  these  cases  appears  upon  the  well-known  sore  under 
the  tongue,  in  addition  to  its  occurrence  upon  other  parts.  The 
secondary  form  of  diphtheria  requires  the  s{ime  treatment  as  the 
primary  form. 

Hauke,  in  1862,  published  experiments  which  showed  that  both  car- 
bonic acid  and  ammoniacal  vapors  when  inhaled  increase  the  cough, 
while  the  inhalation  of  oxygen  produced  no  cough  and  Avas  agreeable 


PAROTIDITIS.  339 

to  the  patient.  Hence  children  in  close  and  crowded  apartments  suffer 
most  severely  from  pertussis,  and  those  who  are  taken  to  parks,  or  the 
country,  Avhere  vegetation  absorbs  the  carbonic  acid,  not  only  obtain 
benefit  from  the  general  invigorating  influence,  but  also  as  regards  the 
cough.  The  fact  that  fresli  and  pure  air  benefits  the  cough  has  indeed 
lone  been  known,  and  has  influenced  practice,  for  patients  are  almost 
universally  allowed  to  be  much  of  the  time  in  the  open  air,  and  are 
taken  to  the  parks  and  upon  excursions.  Nevertheless  caution  in  this 
ret^ard  is  required,  for  exposure  in  wet  weather  or  to  sudden  changes  of 
temperature  is  very  apt  to  develop  bronchitis  or  pneumonia. 

Prophylaxis. — Pertussis  is  very  contagious,  and  it  appears  to  be, 
in  nearly  all  instances,  if  not  in  all,  contracted  by  inhaling  -the  breath 
of  the  patient.  Ijiave  never  observed  a  case  in  Avhich  it  seemed  to  be 
communicated  through  a,  third  person,  and  it  is  not,  I  think,  usually 
contracted  by  children  living  in  the  same  house,  if  there  be  no  personal 
contact.  There  is  not,  therefore,  that  urgent  need  of  disinfection,  and 
of  caution  on  the  part  of  the  physician  and  'nurse  in  their  subsequent 
intercourse  with  healthy  children,  as  in  case  of  the  eruptive  fevers. 


CHAPTEK   II. 

PAKOTIDITIS. 

Ordinarily,  parotiditis,  or  parotitis,  or  mumps,  has  nojpremonitory 
stage  ;  but  in  exceptional  cases  languor  with  fever  precedes  the  disease 
for  a  few  hours.  Mumps  commences  with  tenderness  in  the  parotid 
region,  followed  soon  after  by  tumefaction.  The  swelling  gradually 
increases ;  it  fills  the  depression  under  the  ear,  extends  forward  and 
upward  u])on  the  cheek,  and  downward  to  a  greater  or  less  extent  upon 
the  neck.  It  has  been  demonstrated  in  cases  of  symptomatic  parotiditis, 
and  the  same  is  probably  true  of  the  idiopathic  disease  or  mumps  (Vir- 
chow),  that  the  swelling  is  due  to  inflammation  of  the  gland-ducts  and 
consc(|iient  a'dcma  of  the  interstitial  tissue.  The  inflammation  is  sj)e- 
cific,  due  to  a  materies  morbi  in  the  blood,  and  hence  its  decline  after 
a  fixed  period.  It  reaches  its  maximum  from  the  third  to  the  sixth 
day.  The  most  prominent  point  at  this  time  is  immediately  underneath 
the  lobule  of  the  ear.  The  tumor,  which  is  firm,  but  slightly  elastic, 
presses  outward  the  lobule.  In  most  cases  the  skin  preserves  its  nor- 
mal appearance  over  the  swelling,  but  occasionally  it  presents  a  fiint 
blusli.  ^riie  pressure  which  movements  of  the  jaw  produce  on  the 
gland  renders  mastication  and  even  tidking  painful.  Febrile  move- 
ment more  or  less  intense  occurs,  lasting,  in  ordinary  Civses,  not  more 
than  ^jrty-eight  hours,  but  occJisionally  it  is  more  protracted.  Vomit- 
ing and  epistaxis  are  sometimes  present.     The  swelling  having  attained 


340  PAROTIDITIS. 

its  maximum  size  remains  stationary  a  short  time,  when  it  begins  to 
decline,  and  by  the  sixtli  to  tenth  day  it  has  entirely  subsided. 

In  niost  cases  parotiditis  is  double ;  it  commences  on  one  side,  more 
frequently  the  left  than  right,  and  in  from  ojie  to  fqur^dajs  the  oppo- 
site gland  is  involved.  In  those  exceptional  cases  in  which  only  one 
parotid  is  affected,  the  op})osite  gland  may  be  the  seat  of  the  disease  at 
some  subsequent  period.  It  has  been  estimated  that  the  proportion  of 
unilateral  to  double  mumps  is  as  one  to  ten. 

The  total  duration  of  parotiditis  is  usually  from  eight  to  ten  days ; 
in  the  mildest  cases  it  may  not  be  more  than  five  days.  The  submax- 
illary glands  are  often  involved  in  connection  with  the  parotids,  and 
sometimes  also  the  sidjlingual,  although,  from  their  small  size  and  con- 
cealed position,  their  tumefaction  escapes  notice.  Rarely  the  tonsils 
are  also  tumefied.  Free  perspiration  occurs  at  the  commencement  of 
convalescence  in  certain  patients. 

The  swelling  of  the  parotids  sometimes  abates  sud<lenly,  and  in  the 
male  the  testicle,  epididymis,  and  tunica  vaginalis  become  inflamed ; 
Avhile  in  the  female  the  mammary  glands,  ovaries,  or  the  labia  majora 
are  the  seat  of  the  so-called  metastasis.  Occasionally  these  inflamma- 
tions, which  are  less  frequent  in  young  children  than  those  near  the  age 
of  puberty,  when  the  sexual  organs  are  becoming  more  developed, 
occur  without  subsidence  of  the  parotid  swelling.  They  cause  consider- 
able increase  in  the  fever  and  constitutional  disturbance,  but  Avith  proper 
treatment  decline  in  six  to  eight  days,  pursuing  the  same  course  as  the 
parotid  inflammation. 

Nature. — Parotiditis  is  contagious.  It  is  rare  in  infancy  and  after 
the  middle  period  of  life,  occurring  chiefly  in  childhood,  youth,  and 
early  manhood.  An  incubative  period  of  about  twelve_day^s  was  ascer- 
tained by  me  in  cases  under  observation  in  the  Protestant  Episcopal 
Orphan  Asylum  of  this  city.  The  observations  of  others  give  a  similar 
result.  Parotiditis  is  a  blood  disease,  having  the  local  manifestation 
described  above,  and  which  is  our  only  means  of  diagnosis. 

Diagnosis. — If  the  physician  has  seen  but  fcAv  cases  of  mumps 
there  is  danger  that  he  may  mistake  the  swelling  for  an  inflamed  cer- 
vical gland,  or  vice  versa,  but  an  inflamed  cervical  gland  presents  to 
the  finger  a  hardness  almost  like  that  of  cartilage,  and  it  is  circum- 
scribed  or  round,  and  does  not  invest  the  ear.  These  characteristics 
contrast  with  the  elasticity,  seat,  and  shape  of  the  parotid  swelling, 
which  extends  foi'ward  on  the  cheek  and  surrounds  and  elevates  the 
lobule  of  the  ear.  Tumefaction  resulting  from  diphtheritic  or  any 
other  form  of  faucial  inflammation,  or  from  periostitis  aff'ecting  the  root 
of  the  posterior  molar,  may  be  detected  by  examining  the  fauces  and 
interior  of  the  mouth. 

Treatment. — This  is  very  simple.  Oakum  or  carded  avooI  may  be 
bound  over  the  swelling,  and  the  surface  occasionally  rubbed  with  SAveet 
oil.  Mild  laxatives  and  diaphoretic  drinks,  such  as  bi tartrate  of  potas- 
sium or  lemonade,  are  useful.  If  metastasis  occur,  the  new  local  affec- 
tion should  receive  attention.  It  should  be  treated  in  the  same  manner 
as  if  it  occurred  independently  of  the  mumps,  while  emollient  poultices 


TREATMENT.  341 

or  fomentations  should  be  applied  over  the  parotids.     The  ill-effects  of 
repellant  applications  in  mumps  are  shown  by  the  following  case : 

On  March  19,  1877,  I  was  requested  to  see  a  young  gentleman  of 
eighteen  years.  He  had  been  well  till  March  14th,  when  he  complained 
of  paiu  below  his  ears,  and  hi?  mother  applied  a  towel,  wrung  out  of  cold 
water,  around  his  neck.  On  the  following  day  slight  swelling  was 
observed  under  the  angle  of  the  lower  jaw%  on  the  right  side  (submaxillary 
gland),  and  the  cold  application  was  continued.  On  the  17th  the  swell- 
ing had  disappeared,  but  the  fever  and  headache  had  greatly  increased, 
so  that  he  was  compelled  to  lie  in  bed.  On  the  19th,  at  my  first  visit,  he 
had  such  violent  headache,  aud  was  so  intolerant  of  light  and  noise,  that 
I  greatly  feared  that  he  had  acute  encephalitis.  All  swelling  under  the 
ears  was  gone ;  the  left  testicle  w'as  tender,  and  beginning  to  swell ; 
axillary  temperature  102°.  The  cold  cloths  were  removed  from  the  neck 
and  a|)plied  to  the  head,  and  potass,  bromid.,  gr.  xxv,  administered  every 
third  hour.  20th.  Axillary  temperature  104^  ;  symptoms  unabated  and 
alarming.  Onlered  six  leeches  to  be  applied  upon  the  temples  and  left 
groin,  and  a  purgative,  and  two  drops  of  the  tincture  of  aconite  to  be  given 
with  each  dose  of  the  bromide.  21st.  Temperature  103°.  States  that 
numbness  and  a  pricking  sensation  which  he  had  felt  in  both  legs  during 
the  last  forty-eight  hours  ha<l  ceased  (possibly  from  the  aconite).  2-')d.  Is 
convalescent.  Has  no  return  of  the  swelling  under  the  ears,  and  the 
orchitis  has  abated. 


SECTION  lY. 

OTHER  GENERAL  DISEASES. 


CHAPTER    I. 

INTERMITTENT  FEVER. 

This  is  a  constitutional  malady  produced  by  a  miasm  which  emanates 
from  the  soil.  I  have  notes  of  36  cases  of  this  disease  occurring  under 
the  age  of  3J  years.  Several  of  these  patients  were  treated  in  pri- 
vate practice,  and  the  rest  in  institutions  with  which  I  have  been  con- 
nected. In  children  above  the  age  of  3|  years  intermittent  fever  differs 
but  little  from  that  of  the  adult,  while  in  those  under  this  age  it  pre- 
sents certam  peculiarities.  Of  the  36  cases  which  I  have  observed,  19 
had  the  quotidian  form,  10  the  tertian,  2  the  tertian  becoming  after- 
ward quotidian,  1  the  quotidian  becoming  afterward  tertian,  while  in 
the  remaining  4  cases  the  form  of  the  disease  is  not  stated.  In  quo- 
tidian ague  the  malaria  has  been  supposed  to  act  more  powerfully  on 
the  system,  or  the  system  is  more  susceptible  to  its  influence  than  in 
the  tertian  form,  and  hence  the  fact  that  the  quotidian  is  the  prevailing 
type  of  ague  in  tropical  regions,  where  vegetation  is  luxuriant,  marshes 
extensive,  and  the  heat  intense.  According  to  this  theory,  the  feeble 
resisting  power  in  the  system  of  the  infant  explains  the  fact  that  it  has 
quotidian  more  frequently  than  tertian  intermittent,  although  the  latter 
is  much  more  common  in  the  adult  in  this  climate. 

Facts  demonstrate  that  infants  sometimes  receive  intermittent  fever 
from  their  mothers.  If  mothers  during  gestation  have  malarious 
cachexia,  their  infants,  whether  born  at  full  time,  or,  as  often  happens, 
prematurely,  are  apt  to  be  small,  thin,  and  feeble,  and  occasionally 
they  have  soon  after  birth  distinct  paroxysms  of  the  ague.  Dr.  Stokes 
related  the  case  of  a  pregnant  woman  with  ague,  who  believed  that  she 
noticed  periodical  tremors  of  her  foetus,  but  I  suspect  that  she  was  mis- 
taken as  regards  the  cause,  for  the  paroxysm  of  intermittent  in  young 
children  is  not  ordinarily  accompanied  by  tremors. 

The  youngest  infant  in  my  practice  who  apparently  derived  the  ague 
from  its  mother,  and  probal)ly  through  the  fcjetal  circulation,  had  the 
following  history :  Its  mother  had  occasional  attacks  of  tertian  inter- 
mittent during  the  two  years  preceding  her  confinement,  and  her  bal)y 
when  one  week  old  was  observed  to  have  the  same  disease,  occurring 
also  each  second  day,  the  coldness  and  blueness  in  the  first  stage  of  the 
paroxysm  lasting  from  half  an  hour  to  one  hour. 
(  342  ) 


SYMPTOMS.  343 

It  is  not  fully  ascertained  whether  a  nursing  infant  may  contract 
intermittent  fever  by  lactation,  but  if  it  be  admitted  that  it  is  sometimes 
communicated  to  the  foetu=;  through  the  maternal  circulation,  it  does 
not  seem  improbable  that  the  specific  principle  occasionally  enters  the 
milk  as  well  as  other  secretions.  I  have  frequently  remarked  the  pres- 
ence of  the  disease  in  nursing  infants  whose  mothers  were  affected,  and 
in  one  instance,  an  infant  at  the  breast,  whose  mother  had  the  ague, 
havinsT"  contracted  it  in  a  suburban  villao;e,  but  was  since  livinsr  in  a 
non-malarious  part  of  the  city,  presented  evident  symptoms  of  the  dis- 
ease. Similar  observations  by  Frank,  Burdel,  and  others,  do  not  indeed 
fully  pi'ove  the  communicability  of  intermittent  fever  by  lactation,  but 
render  it  highly  probable. 

The  period  of  incubation  in  the  infant  varies  greatly,  as  in  the  adult. 
When  the  malaria  is  concentrated  and  unusually  active,  or  the  con- 
dition of  system  is  favorable  for  its  reception,  the  disease  may  commence 
soon  after  exposure.  Thus,  in  tropical  regions,  travellers  exposed  for 
a  single  night  have  been  known  to  sicken  within  twenty-four  hours; 
but  in  our  cooler  latitude,  a  longer  incubative  period  is  the  rule.  In 
the  inf  mt,  however,  in  our  climate,  intermittent  fever  often  begins  in  a 
very  sliort  time  after  exposure,  though  there  may  be  an  incubative  period 
of  some  weeks.  The  following  have  been  my  observations  relating  to 
this  point:  A.  M.,  female,  8  months  old,  remained  two  days  on  Long 
Island,  in  October,  1870.  and  three  days  after  her  return  to  the  city  a 
quotidian  commenced.  P.  S.,  male,  11  months  old,  remained  three 
days  on  Long  Island,  and  a  quotidian  commenced  four  days  after  his 
return.  K.,  9  months  old,  remained  on  Staten  Island  one  week,  and 
eleven  days  after  his  return  a  tertian  commenced.  G.  K.,  aged  3 
years,  remained  a  day  and  a  night  on  Staten  Island  in  1870 ;  three 
weeks  afterward  intermittent  fever  commenced,  preceded  by  a  week  of 
languor.  A.  U.,  female,  aged  2  years  and  2  months,  had  the  first 
paroxysm  of  a  tertian,  two  and  a  half  weeks  after  returning  from  a  visit 
of  one  week  in  lloboken.  As  there  was  no  malaria  in  the  portions  of 
tlie  city  where  these  infants  resided,  the  incubative  periods  are  nearly 
a-scertained. 

Whatever  may  be  tlie  nature  of  the  malarial  poison,  whether  a  vege- 
tabh^  cell,  as  Prof  Salisbury  believes,  or  something  else,  it  often  clings 
tenaciously  to  tlie  system,  ami  is  probably  reproduced  in  it,  even  under 
circumstances  favorable  for  its  elimination.  Thus,  at  one  of  my  clin- 
iqui.'s  at  Bellevue  Hospital  Medical  College  in  1871,  a  child,  10  years 
old,  was  presented,  who  iiad  had  every  year  for  seven  years  attacks  of 
intermittent  fever.  The  disease  was  contracted  at  the  age  of  three 
years  in  Harlem,  and  the  subsequent  residence  of  the  family  had  been 
in  a  |)art  of  the  city  where  there  was  no  malaria. 

Symptoms. — Tn  infancy,  and  especially  prior  to  the  age  of  eighteen 
months,  the  symptoms  differ  in  certain  respects  from  those  which  char- 
ai^terize  the  malady  in  the  adult,  and  are  universallv  known.  In  child- 
hood the  symptoms  arc  similar  to  those  in  the  ailult,  and  iuhmI  not, 
therefore,  be  described  in  this  connection. 

In  the  infant  the  type  as  we  have  seen  is  quotidian,  with  now  and 
then  a  tertian.     Advancing  beyond  the  age  of   eighteen  months,  we 


344  INTERMITTENT    FEVER. 

meet  move  and  more  eases  of  the  tertain  type,  and  in  childhood  it  is 
the  common  form.  I  have  known  the  quotidian  in  the  infant,  when 
cured,  to  reappear  a  few  weeks  later  as  a  tertian  ;  but  ortlinarily  it 
remains  quotidian,  unless  the  patient  have  reached  the  age  at  which  the 
tertian  type  predominates. 

The  paroxysm  in  the  young  infant  presents  three  stages,  as  in  the 
adult,  but  while  the  second,  or  febrile,  is  well  marked,  the  first  and 
third  are  much  less  pi'onouuced.  The  patient  does  not  shake  (excep- 
tionally, one  does  even  within  the  first  year)  in  the  first  stage,  but  a 
slight  tremor  may  or  may  not  be  observed.  The  countenance  presents 
a  sunken  appearance ;  the  lips  and  fingers  are  livid,  Avhile  portions  of 
the  surface  not  livid  are  pallid,  with  the  goose-flesh  appearance,  which 
is,  however,  less  marked  than  in  children  of  a  more  advanced  age.  The 
blood  leaves  the  surface,  which  consequently  shrinks,  while  it  accumu- 
lates in  the  veins  and  internal  organs ;  the  pulse  is  feeble,  and  n^adily 
compressed;  the  surfice  grows  cool  from  the  diminished  supply  of  blood, 
but  the  breath  is  warm,  and  the  internal  temperature,  so  tixr  from  being 
reduced,  is  elevated  two  or  three  degrees.  The  parents  may  be  alarmed 
at  the  sudden  sinking  of  the  vital  powers,  and  seek  medical  advice,  but 
in  other  instances  the  first  stage  is  so  slight  that  it  passes  unperceived, 
till  they  have  been  taught  to  watch  for  it,  and  the  second  stage  first 
attracts  attention. 

In  the  second  or  febrile  stage,  which  immediately  succeeds,  the  pulse 
becomes  full  and  rapid,  120  to  130  or  140  beats  per  minute,  and  the 
external  as  well  as  internal  temperature  is  elevated  as  in  few  other  dis- 
eases (104°-108°).  The  face  is  flushed,  surface  dry,  and  head  painful, 
as  evinced  by  the  features.  This  stage  lasts  about  two  or  three  to  six 
or  eight  hours.  The  third  stage,  or  that  of  perspiration  succeeds,  which 
terminates  the  suffering  of  the  patient  till  the  following  paroxysm.  In 
infancy  the  perspiration  is  not  abundant,  and  in  the  first  half  of  this 
period  is  nearly  absent.  In  the  interval  of  the  paroxysm  the  patient 
appears  well,  except  a  degree  of  languor. 

In  twenty-four  of  the  cases  of  infantile  intermittent  which  I  have 
treated  my  notes  describe  the  character  of  tlie  paroxysms.  In  sixteen 
of  these  there  was  no  chill  or  tremblino;  in  the  first  stage,  but  blueness 
and  coolness  of  the  extremities  and  features,  and  sudden  prostration. 
This  stage  lasted  from  ten  minutes  to  one  hour.  In  the  eight  remain- 
ing cases  the  infants  were  observed  to  tremble  or  shake  as  in  adult  cases. 
The  perspiration  of  the  third  stage  was  in  nearly  all  cases,  when  ob- 
served, slight  and  of  short  duration,  but  in  some  it  was  not  observed. 

During  the  cold  stage,  passive  congestion  of  the  internal  organs  occurs 
to  a  greater  or  less  extent,  but  the  circulation  is  equalized  during  the 
reaction  of  the  second  stage.  The  spleen,  whose  capsule  is  distensible, 
soon  enlarges  in  many  patients,  in  consequence  of  the  fre([uent  and  great 
congestions,  constituting  the  "ague  cake.'"  This  enlargement  is  more 
common  in  children  than  adults.  Since  my  attention  has  been  par- 
ticularly directed  to  this  subject,  I  have  been  able  to  feel  the  enlarged 
spleen,  by  examination  through  the  abdominal  walls,  in  probably  one- 
third  of  the  cases  under  the  age  of  ten  years.  This  organ  returns  to 
the  normal  size  after  the  ague  is  cured.     From  the  intimate  relation  of 


SYMPTOMS.  3-15 

the  spleen  to  the  composition  of  the  blood,  it  is  evident  that  the  char- 
acter of  this  fluid  must  be  affected  if  intermittent  fever  be  protracted. 
The  blood  becomes  more  and  more  impoverished,  and  a  state  of  de- 
cided hydriemia  supervenes.  .A  few  weeks'  continuance  of  the  ague 
suffices  to  produce  decided  pallor  of  the  features,  and  surface  generally, 
and  as  all  watery  blood  is  prone  to  transudation,  such  patients  not  infre- 
quently present  more  or  less  oedema  of  the  face,  ankles,  and  other  parts. 
Sometimes,  also,  especially  under  unfavorable  hygienic  circumstances, 
pur})uric  spots  (purpura  hemorrhagica)  appear  under  the  skin,  affording 
additional  proof  of  the  change  which  the  blood  has  undergone. 

In  long-continued  cases  of  malarial  disease  in  the  adult  waxy  degen- 
eration of  organs  is  apt  to  occur,  as  well  as  melanfiemia.  Pigment  cells, 
flakes,  and  particles  appear  in  the  blood,  the  coats  of  the  minute  arteries, 
and  in  various  organs,  as  the  spleen,  liver,  etc.  In  the  child  these  re- 
sults are  more  rare. 

Intermittent  fever  in  children,  if  proper  remedial  measures  are  em- 
ployed at  an  early  period,  is  ordinarily  not  dangerous,  and  is  quite  amen- 
able to  treatment ;  but  that  comparatively  infre(i[uent  and  fatal  form  of 
it,  designated  the  pernicious,  occurs  more  fre([uently  in  children  than 
adults.  In  New  York  City,  where  the  type  of  malarial  diseases  is  mild, 
I  have  never  met  a  case  of  pernicious  intermittent  in  the  adult,  but  I 
can  recall  to  mind  such  cases  in  children,  two  of  them  fatal.  This  form 
of  the  fever  occurs  in  a  smaller  proportionate  number  of  cases  in  infancy 
than  in  childhood,  probably  because  the  cold  stage  is  less  pronounced. 
In  the  pL'rnicious  ague  the  system  is  overpowered — it  does  not  react  in 
a  degree  commensurate  with  the  intensity  of  the  disease.  The  patient 
enters  the  cold  stage,  becomes  stupid,  and,  if  not  relieved  by  prompt  and 
efficient  measures,  passes  into  fatal  coma.  A  type  of  the  disease,  there- 
fore, which  would  not  be  pernicious  in  a  robust  individual,  may  be  such 
in  one  of  a  broken-down  constitution  and  feeble  reactive  power.  In 
most  cases  occurring  in  children  the  coma  is  preceded  by  eclampsia, 
wiiich  is  apt  to  be  general  and  protracted. 

Eclamj)sia  increases  the  passive  congestion  of  the  cerebro-spinal  axis 
already  present  in  this  stage,  and  if  not  speedily  relieved  may  end  in 
transudation  of  serum  over  the  surface  of  the  brain,  and  perhaps  menin- 
geal apoplexy,  causing  fatal  coma.  This  has  occurred  tw'ice  in  my 
practice. 

Sometimes  in  young  children  the  diagnosis  of  intermittent  fever  is 
doubtful,  either  because  the  disease  has  not  continued  sufficiently  long, 
or  there  has  not  been  the  characteristic  paroxysm.  The  patient  may 
l)e  feverish,  antl  fretfid,  with  anorexia,  and  evidences  of  headache,  but 
witlioiit  the  usual  distinctive  synqitoms.  I  have  sometimes  in  such 
cases  been  able  to  establish  the  diagnosis  by  detecting  enlai-gement  of 
the  spleen.  In  examining  for  the  "  ague  cake,"  the  child  must  lie 
(piietly  on  its  back,  and  the  fingers,  placed  midway  between  the  epigas- 
triuui  and  umbilicus,  be  carried  gently  but  with  firm  pressure  outward 
in  the  direction  of  the  spleen,  when  the  anterior  edge  of  this  organ  will 
b(!  felt,  if  it  be  enlarged.  It  is  impossible  to  make  tlu*  e.\:iiiiiii;ition 
when  the  child  cries,  on  account  of  the  contraction  of  the  abdominal 
muscles. 


8-i6  INTERMITTENT    FEVER. 

Treatment. — It  is  evident  that  no  time  should  be  lost  in  applying 
appropriate  remedies  in  a  case  of  infantile  ague ;  for,  although  the  first 
paroxysm  may  be  mild,  the  next  may  be  more  severe,  and  attended  by 
danger.  Moreover,  the  sooner  the  disease  is  cured,  the  less  liable  it 
seems  to  be  to  return.  Therefore  we  prescribe  at  once  the  sulphate  of 
quinia  or  cinchona,  one  and  a  half  grains  of  the  latter  producing  the 
effect  of  about  one  grain  of  the  foi-mer.  Our  experience  in  the  children's 
class  in  the  Outdoor  Department  has  been  chiefly  with  the  sulphate  of 
cinchona,  on  account  of  its  cheapness,  and  there  has  yet  been  no  case 
of  ague  which  it  has  failed  to  control.  A  recent  writer  has  published 
statistics  showing  his  success  in  curing  intermittent  fever  by  this  agent, 
but  nothing  in  therapeutics  is  more  easy  than  to  cure  this  disease  in  our 
climate  by  either  of  the  sulphates  mentioned.  The  chief  difficulty  con- 
sists in  preventing  a  return.  To  an  infant  of  two  years  I  prescribe  one 
grain  of  sulphate  of  quinia,  or  the  equivalent  of  sulphate  of  cinchona, 
three  times  daily,  till  all  symptoms  of  the  ague  have  disappeared;  then 
twice  a  day  during  the  subsequent  week,  and  afterAvard  once  a  day  for 
some  days;  and  finally  twice  or  thrice  a  week.  It  is  only  by  the  pro- 
tracted use  of  the  drug  in  occasional  doses  that  the  return  of  the  inter- 
mittent can  be  prevented. 

It  is  important  in  administering  these  sulphates  to  infants  to  cin])loy 
a  vehicle  which  will,  so  far  as  possible,  disguise  the  ])itterness.  The 
vehicle  which  I  prefer  for  their  administration  is  the  elixir  ndjuvans  or 
elixir  tarax.  co.     The  following  formula  is  for  a  child  of  three  years  : 

R  . — Quiniie  sulphat.         ......         jrr-  xij. 

ISyr.  pruiii  virginiani         .....        SJ*s. — Misce. 

The  following  is  also  a  good  formula: 

U. — Quiniffi  sul[)hat gr.  xvi. 

Ext.  glycyrrhizaa      ......  .^i. 

Syr.  rubi.  idxi.,  (Raspberry)     ....  gij. — Misce. 

One  teaspoonful  three  to  five  times  daily.  The  first  dose  should  be 
given  immediately  after  the  fever  abates.  In  this  climate  two  or  three 
days  suffice  to  cure  the  disease,  after  which  by  daily  but  gradually  dim- 
inished use  of  medicine  in  the  manner  stated  above,  the  return  of  the 
malady  is  prevented.  Protracted  cases  attended  by  anasmia  require  the 
use  of  iron  in  addition  to  the  remedy  which  is  designed  to  control  the 
disease. 


REMITTENT    FEVER.  347 


CHAPTEE  11. 

REMITTENT  FEVER. 

If  a  physician  was  to  consult  the  standard  treatises  on  diseases  of 
children  in  order  to  ascertain  the  nature  of  intermittent  fever,  he  would 
rise  from  the  perusal  with  no  clear  idea  of  it.  One  tells  us  that  the 
remittent  fever  of  children  is  identical  with  typhoid  fever  of  adults; 
another,  that  it  is  a  gastro-intestinal  inHammation ;  and,  finally,  llillier 
believes  that  there  is  properly  no  such  disease,  and  that  the  term  should 
be  dropped  from  the  nosology  of  diseases  of  children.  There  is,  how- 
ever, a  remittent  fever  of  children  as  well  as  adults,  and  much  of  the 
confusion  which  exists  in  reference  to  it  arises  from  the  fact  that  writers 
have  not  kept  in  view  what  constitutes  a  fever. 

Febrile  action  which  has  a  local  cause  is  not  an  essential  fever,  and  should 
not  be  described  as  such.  It  happens  tfiat  in  children  a  symptomatic 
remittent  fever  arises  from  a  variety  of  local  causes,  as  dentition,  intes- 
tinal worms,  subacute  gastro-intestinal  inflammation,  etc.  But  all  such 
cases  should  be  excluiled  from  our  consideration  of  remittent  fever,  as 
clearly  as  we  distinguish  the  continued  fever  of  pneumonia  or  bronchitis 
from  that  of  typhus  or  typhoid. 

There  is  an  essential  remittent  fever  of  children  due  to  malaria.  The 
same  conditions  which  produce  intermittent  fever  do,  in  a  certain  pro- 
poi'tion  of  cases,  produce  a  fever  which  does  not  intermit,  but  continues 
witii  more  or  less  pronounced  exacerbations  a  certain  number  of  days, 
when  it  ceases  or  becomes  intermittent.  Those  who  practise  in  mala- 
rious localities  notice  a  larger  proportion  of  cases  of  remittent  fever 
among  children  than  adults,  because  their  constitutions  are  less  able  to 
resist  the  malarial  poison,  so  that  an  exposure  which  in  an  adult  would 
produce  mihler  disease,  namely,  a  tertian  ague,  frequently  causes  a  (pio- 
tidiau  or  reuiittent  in  tiie  child.  In  young  and  feeble  infants  the  i)ro- 
portionate  number  who  have  remittent  fever  is  large.  Cases,  too,  are 
not  infre(|uent  in  localities  not  malarious,  of  a  remittent  fever  occurring 
more  fre<(uently  in  the  spring  and  autumn  than  in  other  seasons.  Some 
of  these  cases  are  perhaps  a  mild  type  of  typhus  or  typhoid  fever,  but 
in  otiier  instances  the  conditions  do  not  appear  to  be  present  which  ordi- 
narily give  i-ise  to  tliat  disease,  and  tliey  do  not  occur  in  connection 
with  cases  of  typhus  or  typhoid  in  adults.  The  cause,  tliougli  obscure, 
is  apparently  atmospheric. 

The  SYMPTOMS  of  rciiiitttcnt  fcvci-  v;iry  in  different  cases.  Tlie 
exacerbations  and  remissions  ai-e  more  jjronounccMl  in  some  than  others. 
Even  in  those  cases  in  which  tbe  fever  is  due  to  paludid  cniiinations, 
and  occurs  in  connection  with  cases  of  the  intermittent,  the  febrile 
movement  may  he  almost  uniform,  slight  exacerbations  occurritig  in 
the  latter  part  of  the  day.  In  other  cases  the  exacerbations  and  remis- 
sions are  pronounced,  tlie  fcbrih^  excitement  abating  in  a  pers])iration. 


348  TYPHOID    FEVER. 

Occasionally  the  fever  is  liiglier  on  each  second  day.  Cephalalgia  is 
common,  and  in  severe  cases  delirium  and  stupor  are  not  infrequent. 
There  may  be  distinct  remissions  in  the  beginning,  and  afterward,  for 
a  few  days,  the  fever  be  pretty  uniform,  when  it  again  remits  or  ceases. 
The  tongue  is  covered  with  a  light  fur.  Thirst,  loss  of  appetite,  a 
tendency  to  constipation,  scanty  and  high-colored  urine,  containing 
perhaps  urates,  and  a  cough  due  to  mild  bronchitis,  arc  common 
symptoms. 

When  remittent  fever  is  due  to  marsh  emanations,  the  same  ana- 
tomical characters  are  dou1)tless  present  as  in  the  adult,  namely,  blood 
containing  more  or  less  pigmentary  matter,  enlargement  of  the  spleen, 
bronzing  of  the  spleen,  and,  in  some  cases,  of  the  liver,  and  sometimes 
of  the  brain. 

The  DIAGNOSIS  is  not  always  easy.  On  the  one  hand,  local  dis- 
eases with  symptomatic  remittent  fever  are  to  bo  excluded,  and,  on  the 
other,  typhus  and  typhoid.  The  discrimination  of  it  from  typhus  and 
typhoid  fevers  is  practically  of  little  moment,  but  it  is  a  matter  of  vital 
imjjortance  to  make  a  differential  diagnosis  between  it  and  the  local  dis- 
eases. I  have  known  one  of  the  acutest  diagnosticians  and  most  emi- 
nent physicians  of  New  York  mistake  incipient  meningitis  for  it,  a 
mistake  indeed  not  uncommon.  The  points  involved  in  differential 
diagnosis  will  be  considered  in  our  description  of  the  local  disease. 

Treatmext. — If  we  have  ascertained  by  a  careful  examination  that 
the  fever  is  remittent,  and  not  symptomatic,  but  essential,  there  is  one 
remedy  whicli  is  required  in  nearly  all  cases,  namely,  quinia,  or  its 
equivalent,  cinchona.  Mild  febrifuge  medicines,  with  light  diet,  may 
be  first  employed  in  sthenic  cases,  in  which  the  pulse  is  full  and  strong, 
and  the  quinia  given  when  the  fever  has  somewhat  abated.  The  diet 
should  be  bland,  but  nutritious,  and  the  bowels  be  kept  regularly  open 
bv  citrate  of  magnesium  or  other  mild  aperient.  Bromide  of  potassium 
or  hydrate  of  chloral  may  be  occasionally  employed,  as  recommended  in 
the  treatment  of  typhoid  fever,  to  produce  quietude  or  sleep,  in  cases 
attended  by  delirium  or  insomnia.  A  warm  mustard  foot-bath  and  cool 
applications  to  the  head  are  useful  in  such  cases. 


CHAPTER     III. 

TYPHOID  FEVER. 

Typhus  and  typhoid  fevers  occur  in  children,  but  the  former  is  mild 
and  infrecjuent,  rarely  occurring  except  Avhen  adults  of  the  same  house- 
hold are  affected.  It  recjuires  little  treatment,  besides  good  nursing. 
Typhoid  fever,  on  the  other  hand,  is  not  infrequent  in  children,  and, 
as  it  presents  certain   peculiarities  prior  to  the  age  of  puberty,  it  is 


CAUSES.  349 

proper  to  describe  it  in  this  connection.  This  disease  is  much  less 
common  in  infancy  than  in  childhood,  and  in  the  first  half  of  infancy 
is  believed  to  be  rai"e.  Still,  there  can  be  no  doubt  that  many  cases  in 
the  first  years  of  life  are  not  diagnosticated,  being  mistaken  for  subacute 
and  protracted  entero-colitis.  It  is  probably  more  common  under  the 
age  of  six  years  than  is  usually  supposed,  although  the  younger  the 
child  below  this  age  the  less  frequent  does  it  appear  to  be;  while  above 
the  age  of  six  years  it  is  more  and  more  frequent  until  puberty.  In 
the  statistics  of  Cadet  de  Gassicourt,  embracing  276  children,  3  were  at 
the  age  of  two  years,  7  at  the  age  of  three  years,  8  at  four  years,  13  at 
five  years,  and  the  number  gradually  increased  in  successive  years  until 
there  were  32,  41,  and  42  cases  at  the  ages  of  twelve,  thirteen,  and  four- 
teen years. 

Causes. — It  is  now  generally  admitted  that  typhoid  fever  is  mildly 
contagious,  and  that  its  specific  principle  abounds  largely  in  the  dejec- 
tions and  excretions  of  the  patient.  It  is  uncertain,  whether  it  is  com- 
municable by  the  breath  of  the  patient,  or  exhalations  from  his  surface. 
If  it  is,  it  is  slightly  so,  while  numerous  observations  demonstrate  its 
communicability  through  the  use  of  night-stools  or  privies  which  contain 
the  evacuations. 

Many  cases  are  on  record,  in  which  typhoid  fever  was  contracted 
from  drinking  water  which  was  polluted  through  drainage  by  the  stools 
of  typhoid  patients.  Epidemics  of  considerable  extent  and  severity  have 
been  traced  to  this  cause.  This  disease  occurs  more  frequently  in  the 
autumnal  than  in  the  other  months.  Observations  show  that  typhoid 
epidemics  are  most  frequent  and  severe  after  protracted  hot  weather, 
attended  by  a  scanty  rainfall,  and  diminished  Avater  supply.  The  most 
extensive  epidemic  which  I  have  observed  in  New  York  City,  affecting 
largely  children,  occurred  after  the  protracted  hot  weather  of  1882,  in 
which  there  was  great  scarcity  of  Croton  water,  and  the  proper  flushing 
out  of  the  waste  pipes  therefore  impracticable.  To  the  noxious  elHuvia 
engendered  in  the  tenement  houses  under  such  conditions  the  prevalence 
of  the  fever  seemed  to  be  largely  attributable. 

It  is  an  interesting  fact  that  typhoid  fever  is  rarely  contracted  directly 
from  a  i)atient  provided  that  ids  stools  and  soiled  linen  are  promptly 
disinfected  and  removed.  The  virulence  of  the  poison  contained  in  the 
stools  appears  to  increase  after  their  evacuation  ;  hence  the  great  viru- 
lence which  they  acfjuirc  hours  after  they  have  been  removed  from  the 
sick  room,  and  have  contaminated  the  drinking-water. 

There  is  little  doubt  Jilso  that  typhoid  fever  originates  de  novo, 
eaused  by  the  miiism  produced  by  decaying  animal  or  vegetable  matter. 
Numerous  cases  have  been  observed  in  which  it  originated  from  defec- 
tive sewerage,  or  decaying  vegetables  in  cellars,  in  loealities  in  which 
no  case  had  previously  been  observed.  The  germs  of  the  disease  when 
it  originates  under  such  circumstances  may  ])robably  be  received  into 
the  system  by  inspiration  and  in  the  ingesta.  The  use  of  well-water 
which  is  contaminated  with  sewer  drainage  has  been  repeatedly  known 
to  produce  it.  It  has  even  been  traceii  to  impure  water  used  in  rinsing 
milk-cans  which  contaminated  the  milk,  and  to  ini]»iire  ice  which  coji- 
taincd  the  subtle  specific  principle.     Boys  are  more  frequently  attacked 


350  TYPHOID    FEVER. 

than  girls ;  according  to  some  statistics,  in  the  proportion  of  three  to 
one.  Deterioration  of  the  health  from  general  causes  increases  the  lia- 
bility to  be  attacked.  On  the  other  hand,  those  having  tuberculosis, 
carcinoma,  heart  disease,  and  probably  certain  other  visceral  lesions, 
are  more  apt  to  escape  than  those  in  health. 

Klebs  believes  that  he  has  discovered  the  specific  principle  of  typhoid 
fever  in  a  microorganism  which  he  designates  the  bacillus  typhosus.  It 
occurs  in  the  form  of  little  rods,  each  containing  a  spore  at  the  centre 
and  often  one  at  the  end,  which  spores  form  new  bacilli.  He  believes 
that  the  bacilli  enter  the  system  both  by  the  respiratory  passages  and 
alimentary*  canal. ^  He  found  numerous  bacilli  of  this  kind  in  Peyer's 
})atches.  Eberth  has  also  found  rod  bacteria  in  the  intestinal  mucous 
membrane,  mesenteric  glands,  and  spleen  in  typhoid  fever,  which 
appear  to  vary  from  other  rod  bacteria  by  a  difference  in  staining.  In 
seventeen  cases  these  bacilli  were  found  in  six,  and  not  found  in  eleven.^ 
Wernich,  on  the  other  hand,  believes  that  the  rod  bacteria  of  Klebs 
and  Eberth  are  the  bacteria  subtilis  common  in  the  large  intestine, 
which  have  undergone  further  development,  acquired  new  properties, 
and  perhaps  have  become  the  cause  of  disease.^  It  is  evident  that  it 
is  still  very  uncertain  Avhether  the  specific  principle  of  typhoid  fever  has 
been  discovered.  The  test  of  cultivation,  and  the  propagation  of  the 
disease  from  the  cultivated  microbe,  are  lacking. 

Anatomical  Characters. — Since  typhoid  fever  is  a  constitutional  dis- 
ease, we  Avould  expect  to  find  early  and  important  changes  in  the  blood. 
No  alteration,  however,  has  been  discovered  in  this  fluid  peculiar  to 
typhoid  fever.  The  amount  of  fibrin  is  diminished  as  in  most  of  the 
essential  fevers,  and  its  coagulation  is  feeble,  forming,  when  the  blood 
stands,  soft,  small,  and  dark  clots.  AVhen  the  fever  has  continued  for 
some  time,  a  state  of  aniemia  more  or  less  decided  supervenes,  in  which 
the  amount  of  albumen  and  blood-corpuscles  is  diminished.  Although 
there  are  often  decided  s^^mptoms  referable  to  the  nervous  system,  no 
constant  changes  have  been  discovered  in  the  brain  or  spinal  cord.  The 
changes  observed  in  them  when  death  has  occurred  in  the  course  of 
typhoid  fever  have  been  for  the  most  part  due  to  other  causes.  It  is 
different  with  the  respiratory  system.  After  the  first  week  of  typhoid 
fever  bronchitis  is  almost  as  constant  as  inflammation  of  the  fauces  in 
scarlet  fever,  and  accordingly  we  find  in  fatal  cases  redness  and  thick- 
ening of  the  bronchial  mucous  membrane,  which  is  covered  with  a  viscid 
and  ordinarily  scanty  secretion.  Hypostatic  congestion  of  the  lungs, 
with  more  or  less  oedema,  and  in  severe  and  enfeebled  cases  hypostatic 
pneumonia,  are  not  uncommon.  In  the  bronchitis  and  state  of  feeble- 
ness we  have  the  causes  of  pulmonary  collapse,  and  this  lesion  is  not 
infrequent  over  limited  portions  of  the  lungs,  especially  if  the  bronchitis 
affect  the  smaller  tubes. 

The  lesions  occurring  in  the  digestive  system  are  important.  The 
mucous  membrane  of  the  small  intestine  is  more  or  less  injected,  and  at 
an  early  period,  even  by  the  second  or  third  day,  the  patches  of  Peyer, 
solitary  glands,  and  at  the  same  time  the  mesenteric,  begin  to  enlarge. 

1  Phil.  Med.  Times,  Dec.  3,  1881.  "^  British  Med   Jour.,  Nov.  26,  1881. 

'  See  article  on  Typhoid  Fever,  System  of  Practical  Medicine,  1885,  Lea  Bros. 


SYMPTOMS.  851 

It  has  been  stated  by  high  authorities  that  the  enlargement  is  due  to 
infiltration  ^vith  a  peculiar  substance,  Avhich  has  been  termed  the  typhus 
material.  I  have  made  microscopic  examination  of  these  glands  in 
typhoid  fever  of  the  adult,  and  have  found  a  considerable  increase  of  the 
small  round  granular  cells  of  which  they  are  composed.  I  do  not,  there- 
fore, doubt  that  the  enlargement  is  due  mainly  to  hyperplasia  of  the 
cellular  elements  of  the  glands,  though  there  is  probably  infiltration  to 
a  certain  extent  of  inflammatory  products  between  the  cells.  The 
mucous  membrane  over  the  glands  undergoes  inflammatory  thickening 
and  softening.  In  the  adult,  sloughing  of  this  membrane  is  frequent, 
with  the  disintegration  of  the  glands  and  their  elimination  into  the  in- 
testines, producing  ulcers,  small  and  circular,  corresponding  with  the 
site  of.  the  solitary  glands,  large  and  oval  or  irregular,  corresponding 
with  the  site  of  the  aizminate.  Disintejjration  of  these  glands  and  the 
formation  of  ulcers  are  less  frequent  in  children  than  in  adults.  In  the 
adult  who  recovers,  the  mesenteric  glands,  and  those  of  the  solitary  and 
agminate  which  are  not  destroyed,  return  to  their  normal  state  by  fatty 
degeneration,  liquefaction,  and  absorption  of  the  redundant  cells.  In 
the  child  this  is  the  common  result,  instead  of  sloughing  and  disintegra- 
tion,  as  regards  both  the  solitary  and  agminate  glands,  and  uniform 
result  as  regards  the  mesenteric,  and  I  may  add  bronchial  glands,  which 
are  also  in  a  state  of  hyperplasia.  The  absence  of  ulceration  or  its 
slight  extent  affords  explanation  of  the  fact  that  intestinal  perforation  is 
very  rare  in  children. 

The  spleen  gradually  enlarges,  often  to  twice  the  normal  size,  has  a 
dark  red  color,  and  is  softened.  Enlargement  of  the  spleen  possesses 
great  diagnostic  value  in  those  cases  in  which  the  diagnosis  is  obscure. 
For  while  very  similar  intestinal  lesions  may  occur  in  chronic  entero- 
colitis, the  coexistence  of  these  lesions  with  the  splenic  enlargement  and 
softening  shows  the  constitutional  nature  of  the  malady. 

In  cases  which  are  severe,  and  which  ])resent  a  decidedly  adynamic 
type,  the  muscles  become  soft  and  flabby,  the  action  of  the  heart  is 
feeble,  and  more  or  less  passive  congestion  of  the  viscera  results.  In 
such  cases  congestion  of  the  kidneys  and  all)uminuria  arc  not  infrecjuent. 

Incuhative  Period. — As  in  scarlet  fever  and  diphthei'ia,  the  incubative 
period  in  ty[)lioid  fever  varies.  In  three  cases  detailed  by  Griesinger, 
the  fever  began  twenty-four  hours  after  exposure.  In  a  school  at  Chip- 
ham  twenty  out  of  twenty-two  boys  sickened,  according  to  jNIurehison, 
within  four  days  after  exposure.  Authenticated  cases  of  a  longer  incu- 
bative period  are  on  record,  so  that  Murchison  believed  that  it  is  com- 
monly about  two  weeks,  and  William  Budd  that  it  is  in  most  instances 
from  ten  to  fourteen  days,  but  cases  have  occurred  in  which  it  seemed 
to  be  as  long  as  twenty-eight  days.^ 

Symptoms. — Typhoid  fever  has  a  ])rodromic  stage  of  a  few  days, 
sometimes  of  a  week  or  more,  in  which  the  child  appears  languid,  indis- 
posed to  play,  and  has  little  appetite,  ])ut  complains  of  no  pain  unless 
occasional  slight  headache,  and  has  no  symptom  which  wouM  h-ad  the 
friends  or  even  physicians  to  suspect  the  grave  nature  of  the  disease 
which  impended.     By  and  by  a  slight  fever  occurs. 

'  See  article  Typhoid  Fever,  System  of  Practiciil  Modicino,  188'),  Loa  Bros. 


852  TYPHOID    FEVER, 

In  exceptional  instances  typhoid  fever  begins  with  a  chill  followed  by 
pronounced  fever.  It  occurred  in  three  of  the  fourteen  cases  observed 
by  Prof.  Jacobi,  in  Bellevue  Hospital.  This  was  a  larger  proportion  of 
cases  with  such  commencement  than  I  observed  in  the  epidemic  of  1882 
or  have  since  observed,  but  the  cases  in  Bellevue  seem  to  have  been 
unusually  severe,  since  five  of  the  fourteen  died. 

The  febrile  movement,  Avhich  gradually  becomes  more  pronounced, 
remits,  but  does  not  cease  in  the  morning,  and  has  evening  exacerba- 
tions. After  the  first  week  of  fever  the  remissions  are  less  marked,  but 
the  fever  is  not  uniform  at  any  period  in  its  course.  Hence  some  of 
our  ablest  writers  on  diseases  of  children  continue  to  designate  typhoid 
fever  of  children  remittent  fever,  fully  aware  of  its  identity  with  typhoid 
fever  of  the  adult.  As  the  case  advances,  the  appetite  fails,  all  solid 
food  being  refused,  and  liquid  food  being  taken  more  from  thirst  than 
huncjer.  The  tono-ue  in  the  first  week,  and  in  some  patients  throuohout 
the  course  of  the  disease,  is  covered  Avith  a  light  moist  fur,  while  in 
others  having  a  graver  type  of  the  fever  the  tongue  after  the  first  Aveek 
is  dry  and  brown.  During  the  prodromic  period,  and  in  the  first  week, 
the  boAvels  act  regularly,  or  are  slightly  relaxed,  and  they  are  readily 
affected  by  purgative  medicines.  After  the  first  week  there  is  in  most 
children  a  tendency  to  diarrhoea,  which  requires  now  and  then  the  use 
of  astringents,  the  stools  being  watery  and  brown,  or  dark  yellow.  The 
abdominal  Avails  are  seldom  retracted,  but  prominent,  especially  after 
the  first  Aveek,  in  consequence  of  meteorism,  Avhich  is  present  in  children 
as  Avell  as  adults.  Sometimes  there  is  apparent  tenderness,  Avhen  pres- 
sure is  made  o\'er  the  right  iliac  region,  but  this  must  not  be  confounded 
Avith  hyperfesthesia,  which  is  common  in  the  commencement  of  febrile 
diseases  in  children,  and  Avhich  is  observed  especially  upon  the  abdomen, 
chest,  and  inner  part  of  the  thighs. 

The  respiration  in  the  first  Aveek  is  slightly  accelerated,  as  it  is  in  all 
febi'ilc  diseases.  In  the  second  Aveek,  and  subsequently  Avhen  bron- 
chitis is  developed,  the  respiration  is  ordinarily  more  accelerated,  though 
not  in  a  marked  degree,  unless  in  those  exceptional  instances  in  Avhich 
there  is  an  abundant  collection  of  mucus  in  the  smaller  bronchial  tubes. 
A  cough  is  often  present,  dependent  on  the  bronchitis,  and  varying  in 
character  according  to  the  degree  and  starre  of  the  inflammation.  In 
the  first  days  of  the  fever  it  is  infrequent,  or  lacking;  at  a  later  stage 
it  is  more  frequent,  and  not  so  dry,  though  in  cases  of  ordinary  severity 
the  amount  of  expectoration  is  inconsiderable.  Hypostatic  congestion, 
oedema,  hypostatic  pneumonia,  splenization,  or  thickening  of  the  alveolar 
Avails,  and  collapse,  Avhich  may,  and  some  of  Avhich  not  infrequently  do 
occur  in  the  advanced  disease,  increase,  more  or  less,  tlie  frequency  of 
the  respiration  and  the  cough,  and  modify  tlie  physical  signs. 

The  pulse  in  the  first  Aveek,  in  ordinary  cases,  is  from  100  to  110  or 
115.  it  gradually  becomes  more  accelerated,  numbering  in  the  second 
week  123  or  more;  in  grave  cases  even  160.  The  more  frequent 
the  pulse,  the  greater  the  danger  and  more  unfavorable  the  prognosis. 
During  the  exacerbations  the  number  of  pulsations  per  minute  is  15  or 
20  more  than  in  the  remissions.  The  change  in  temperature  corre- 
sponds Avith  that  of  the  pulse,  being  from  1°  to  2°  higher  in  the  ex- 


COMPLICATIONS.  353 

acerbation  than  reiaission.  The  extremes  of  temperature  in  cases  of 
ordinary  severity  are  about  101°  to  104°.  A  temperature  above  105° 
shows  a  grave,  probably  a  fatal  type  of  the  disease,  or  else  a  serious 
complication. 

There  is  great  variation  as  regards  the  symptoms  referable  to  the 
nervous  system.  Headache  is  common  in  the  prodromic  and  initial 
stages,  after  which  it  ceases.  A  few  are  delirious  even  from  an  early 
period,  screaming  loudly,  or  muttering  incoherently,  but  the  majority 
are  quiet,  having,  indeed,  a  degree  of  mental  dulness,  but  being  aide  to 
appreciate  questions  when  aroused,  and  ansAvering  correctly.  Subsultus 
tendinura  and  carphologia,  whicli  some  exhibit,  show  that  there  is  pro- 
found disturbance  of  the  nervous  system.  Epistaxis  occurs  occasionally 
in  the  first  week,  as  in  the  adult,  but  is  not  abundant. 

The  rose-colored  eruption  appears  in  children  as  well  as  adults  between 
the  sixth  and  twelfth  days,  but  is  more  frequently  absent  in  the  former 
than  the  later  ;  sometimes  the  number  of  s])Ots  is  less  than  half  a  dozen. 
Sudamina  are  common  in  the  second  and  third -^veeks,  and  perspirations 
may  occur  at  any  time  in  the  course  of  the  fever,  but  without  ameliora- 
tion of  symptoms.  More  or  less  deafness  is  common,  being  in  most 
instances  a  purely  nervous  symptom,  without,  therefore,  any  structural 
change  in  the  ear,  but  it  is  possible,  as  has  been  suggested  by  certain 
writers,  that  it  sometimes  results  from  inflammatory  thickening  of  the 
Eustachian  tube  or  external  meatus,  or  from  a  weakened  and  llabby 
state  of  the  muscles  of  the  ear. 

The  duration  of  typhoid  fever  is  not  uniform  ;  while  mild  cases  may 
end  in  two  weeks,  those  of  a  severer  type  continue  three  or  even  four. 
The  patient  becomes  progressively  more  emaciated  and  feeble.  In  pro- 
tracted and  severe  cases  his  condition  seems  very  unpromising  to  one 
not  familiar  Avith  the  clinical  history  of  the  fever.  Pale,  emaciated,  and 
feeble,  probably  passing  his  evacuations  in  bed,  taking  little  notice  of 
objects  around  him,  he  presents,  at  the  close  of  the  third  week,  an 
appearance  of  lielplessness,  notwithstanding  the  best  of  nursing,  and 
the  constant  employment  of  sustaining  measures,  which  is  truly  dis- 
couraging. 

Complications. — The  chief  comjdications  of  typhoid  fever  are 
broncho-pneumonia,  already  sufficiently  described,  enteritis,  intestinal 
hemorrhage,  peritonitis,  otitis,  parotiditis,  and  muguet.  In  one  in- 
stance I  lost  a  patient  about  ten  years  old,  in  Avhom  the  fever  had 
nearly  terminated,  by  the  sudden  accession  of  crouj).  There  is,  as  we 
liavc  seen,  in  ordinary  cases,  more  or  less  inllammation  of  the  mucous 
membrane  of  the  air-passages,  and  of  the  intestines,  especially,  in  the 
vicinity  of  the  patches  of  Peycr.  It  is  easy  to  understand  how,  under 
circumstances  which  may  arise  in  the  fever  favorable  to  the  develop- 
ment of  mucous  inflammations,  the  In'onchitis  and  enteritis  may  so 
increase  as  to  constitute  complications.  They  are  the  most  frequent  of 
the  serious  complications. 

Feeble  action  of  the  heart,  common  in  severe  cases  of  typhoid  fever, 
and  which  after  the  second  week  is  partly  attributable  to  granulo-fatty 
degeneration  of  the  muscular  fibres  of  the  heart,  Avhich  is  frequent  in 
grave  forms  of  the  infectious  diseases,  obviously  fa\'ors  the  occurrence 

23 


354  TYPHOID    FEVER. 

of  bronchial  and  pulmonary  congestion.  Hence  the  proneness  in  these 
cases  of  the  inflammation  to  extend  downward  from  the  larger  to  the 
smaller  bronchial  tulles  and  to  the  lungs,  So  that  broncho-pneumonia 
becomes  an  occasional  very  grave  complication. 

In  the  child  as  well  as  aihdt  Avith  this  disease,  the  mucous  membrane 
of  the  lower  part  of  the  ileum  in  the  vicinity  of  Peyer's  patches  is 
frequently  thickened  and  hypersemic,  a  true  intestinal  catarrh.  We 
can  readily  understand  how  under  certain  circumstances  this  may 
become  aggravated,  so  as  to  constitute  an  intestinal  inflammation  of 
considerable  extent  and  gravity,  a  severe  entero-colitis,  so  that  the  local 
symptoms  predominate  over  the  constitutional  and  aggravate  the  later. 

In  the  adult,  as  is  well  known,  the  Peyerian  and  solitary  glands 
becoming  more  and  more  prominent  by  proliferation  of  the  celluhir 
elements  (the  lymphoid  cells),  begin  to  ulcerate  in  the  second  week,  and 
slough  in  the  third,  forming  the  typhoid  ulcer,  which  is  slow  in  healing, 
and  aids  in  keeping  up  the  diarrhccal  state.  Such  destructive  or 
necrotic  inflammation  is  rare  in  young  children,  but  it  may  occur  in 
those  of  a  more  advanced  age. 

Intestinal  hemorrhage  is  therefore  an  occasional  accident.  Hillier 
met  four  cases  in  thirty  of  the  fever.  It  indicates  the  presence  of  ulcers 
upon  the  surface  of  the  intestines.  The  younger  the  child,  the  less  the 
liability  to  it.     Some,  in  whom  it  has  occurred,  recover,  but  others  die. 

Intestinal  perforation  is  more  rare  in  children  than  in  adults,  as  might 
be  inferred  from  the  statement  already  made,  tliat  intestinal  ulceration  is 
less  frequent  and  extensive  in  them.  Statistics  show  that  perforation 
occurs  only  once  in  232  cases.  Therefore,  as  perforation  is  the  com- 
mon cause  of  peritonitis  in  this  disease,  this  inflammation  is  a,  rare 
complication.  Peritonitis  may,  however,  occur  in  typhoid  fever  with- 
out j)erforation.  In  one  such  case  (an  adult)  in  the  fever  wards  attached 
to  Charity  Hospital,  local  peritonitis  with  fibrinous  exudation  occurred 
opposite  two  ulcerated  patches  of  Peyer,  the  ulcers  extending  nearly  to 
the  peritoneum,  but  not  perforating.  The  lesions  observed  in  this  case 
throw  light  on  those  cases  of  peritonitis  complicating  typhoid  fever 
which  recover,  the  cause  of  wliich  has  received  a  different  exjjlanation. 

In  advanced  and  greatly  debilitated  cases,  thrush  sometimes  appears 
in  the  interior  of  the  mouth,  and  upon  the  fiiuces.  It  is  always  an 
unfavorable  prognostic  symptom  in  children  suffering  from  chronic  or 
protracted  disease.  Parotiditis  is  also  a  rare  complication.  Otitis, 
commencing  with  pain,  and  producing  a  discharge  wliich  may  continue 
for  weeks,  is  not  rare,  though  loss  frecpu'nt  than  in  scarlet  fever.  The 
otitis  is  commonly  external,  but  it  may,  in  scrofulous  subjects^  extend 
to  the  middle  ear. 

Diagnosis. — This  is  more  difficult  in  children  than  in  adults,  and 
the  younger  the  child  the  greater  the  difficulty.  In  infants  protracted 
entero-colitis,  with  febrile  action  and  dry  furred  tongue,  cannot  in  cer- 
tain cases  be  positively  diagnosticated  from  typhoid  fever  by  the  symp- 
toms and  clinical  history.  Typhoid  fever  is  believed,  however,  to  be 
rare  at  this  age,  for  an  infant  nourished  at  the  breast,  and  rarely  drink- 
ing from  a  cup,  is  very  seldom  exposed  to  the  cause  of  the  disease. 
When,  however,  as  now  and  then  happens,  a  young  child  presents  the 


D  U  K  A  T I O  N  355 

symptoms  characteristic  of  protracted  subacute  entero-colitis,  or  typhoid 
fever,  and  older  members  of  the  household  have  the  fever,  it  is  highly 
probable  that  the  case  is  one  of  the  latter  disease,  and  it  should  be 
treated  accordingly. 

Even  in  older  children  typhoid  fever  is  frequently  mistaken  for  simple 
subacute  enteritis,  or  entero-colitis,  or  vice  versa.  The  following  facts 
aid  in  the  differential  diagnosis.  In  typhoid  fever  there  is  total  loss  of 
appetite,  while  in  the  subacute  intestinal  inflammation  food  is  not 
entirely  refused.  Diarrhoea  commences  early  in  the  inflammation, 
while  in  the  fever  it  is  not  ordinarily  till  after  the  lapse  of  a  few  days. 
Abdominal  tenderness  in  the  fever  is  not  appreciable,  or  is  located  in 
the  right  iliac  region ;  in  the  other  disease  it  is  general  over  the  abdo- 
men, or  located  in  the  umbilical  region.  In  typhoid  fever  there  is 
bronchitis  witli  a  cough  which  is  absent  in  the  inflammation.  In 
tvphoid  fever  there  are  certain  other  symptoms,  more  or  fewer  of  wdiich 
are  present  in  most  cases,  and  which  do  not  occur  in  the  intestinal 
diseases,  except  as  a  coincidence ;  for  exaruple,  headache,  epistaxis, 
stujjor,  delirium,  and  perhaps  the  rose-colored  spots. 

Typhoid  fever  may  be  mistaken  for  meningitis,  during  the  first  week, 
but  in  meningitis  there  is  more  constipation,  irritability  of  stomach,  and 
less  elevation  of  temperature.  Moreover,  in  meningitis,  at  a  compara- 
tively early  stage,  we  are  able  to  detect  patches  of  congestion  of  the 
features  coming  and  disappearing  suddenly ;  and  slight  inequality  of 
the  pupils,  or  their  oscillation  when  the  light  is  uniform;  signs  which 
are  lacking  in  typhoid  fever.  In  a  doubtful  case  the  ophthalmoscope 
mifdit  be  employed,  which  in  meningitis  discloses  congestion  of  tlic 
vessels  of  the  retina,  oedema,  etc.,  anatomical  changes  which  do  not 
pertain  to  typhoid  fever. 

The  differential  diagnosis  of  typhoid  fever  and  acute  tuberculosis 
mav  be  made  by  attention  to  the  following  points.  In  tuberculosis 
there  is  cough,  with  some  acceleration  of  respiration  from  the  first, 
without  epistaxis,  stupor,  or  other  nervous  synqjtoms,  and  without  the 
ab<lominal  symptoms  which  are  so  prominent  in  the  fever. 

Duration. — The  duration  of  typhoid  fever  varies  from  one  to  about 
five  weeks,  but  complications  which  may  arise  may  protract  the  febrile 
movement.  Henoch  states  that  in  eighty  cases  which  came  under  his 
observation,  the  duration  in  7  was  from  7  to  D  days,  in  30  from  10  to  15 
days,  in  31  from  15  to  23  days,  in  7  from  23  to  35  days,  and  in  5 
from  35  to  40  days.  Recovery  from  a  severe  and  protracted  attack  is 
slow,  several  weeks  or  even  months  elapsing  before  complete  resto- 
ration to  health.  A  tendency  to  diarrhoea  often  continues  several 
weeks  after  the  fever  proper  ceases,  necessitating  a  rigid  oversight  of 
the  diet,  and  the  occasional  employment  of  astringents.  The  milder 
the  attack  of  typhoid  fever,  the  less,  as  a  rule,  are  the  intestinal  h'sions, 
ami  since  ulcerations  of  Peyer's  patches  are  absent  or  slight  in  cliildren, 
there  is  little  danger  from  this  source  in  them.  In  the  adult,  on  the 
other  hand,  the  intestinal  disca.se  constitutes  one  of  the  chief  source*?  of 
danger,  and  it  renders  convalescence  uncertain  and  protracted.  Henoch 
states  that  of  137  cases  of  typhoid  fever  in  children  he  lost  oidy  10. 


356  TYPHOID    FEVER. 

Prognosis. — A  mucli  larger  percentage  of  children  recover  than  of 
adults.  Although  there  be  great  emaciation  with  loss  of  strength 
recovery  may  be  confidently  predicted,  provided  that  no  serious  com- 
plication occur.  In  flital  cases  wliich  I  have  met,  the  unfavorable 
result  occurred,  as  a  rule,  from  the  complications,  rather  than  directly 
from  the  malady.  The  condition  in  which  severe  typhoid  fever  leaves 
a  patient  is  favorable  for  the  development  of  tubercles,  and  now  and  then 
they  occur,  disappointing  our  expectations  and  prediction  of  recovery. 

Treatment. — Typhoid  fever,  like  typhus,  cannot  be  abridged  by 
treatment,  and  the  indication  is  to  sustain  the  vital  powers,  diminish 
the  intensity  of  the  febrile  movement,  and  to  control  any  untoward 
symptom  or  complication.  Quinia,  so  useful  in  malarial  diseases,  may 
be  administei'ed  in  small  doses  for  its  tonic  eifect,  and  as  an  aid  in  pro- 
moting digestion.  It  is  commonly  and  properly  prescribed  in  some 
convenient  vehicle  for  this  purpose,  but  it  does  not  antagonize  the 
typhoid,  as  it  does  the  malarial  poison.  Perturbating  medicines,  and 
especially  cathartics,  should  be  given  with  caution.  The  tendency  to 
intestinal  ulceration  and  hemorrhage,  and  the  anaemic  nature  of  the 
fever,  require  abstinence  from  or  cautious  use  of  such  agents.  A  tem- 
perature remaining  under  103°  usually  involves  little  danger.  If  it 
rise  above  that,  antipyretic  measures  should  be  employed.  The  use  of 
salicylate  of  sodium,  large  doses  of  quinine,  and  cold-water  ablutions, 
are  the  three  admissible  remedies  for  tiiis  state.  The  salicylate  I  sus- 
pect impairs  the  appetite,  and  retards  digestion,  and  the  quinine  is  much 
less  efficient  as  an  antipyretic  in  this  fever  than  cold-water  bathing.  I 
therefore  order  the  nurse  to  bathe  frequently  the  forehead,  face,  hands, 
arms,  neck,  and  sometimes  the  chest,  Avith  cold  water,  to  which  it  is 
j^roper  to  add  alcohol  or  some  spirituous  lotion.  A  cloth  wrung  out  of 
ice  water  or  an  ice  bag  should  be  applied  over  the  head,  and  the  hands 
may  be  allowed  to  lie  a  considerable  time  in  a  Avash  bowl  containing  the 
lotion,  Avhich  is  always  grateful  to  the  patient.  The  Avater  treatment 
thus  applied  Avill  usually  reduce  the  temperature  one,  tAVO,  or  three 
degrees  Avithin  a  fcAv  hours. 

In  all  cases  of  typhoid,  as  in  other  essential  fevers,  free  ventilation  is 
required  from  an  open  AvindoAv,  and  the  bedding  and  body  linen  should 
be  changed  every  day. 

Observations  made  during  the  last  dozen  years  appear  to  shoAv  that 
the  mineral  acids  have  a  salutary  effect  upon  the  course  of  the  fev^er. 

The  dilute  nitric,  muriatic,  or  nitro-muriatic  acid  should  be  given 
largely  diluted  Avith  Avater,  and,  if  possible,  through  a  glass  tube  so  as  to 
protect  the  teeth.  I  haA'e  recently  administered  the  dilute  muriatic  acid 
in  the  acidulated  liquid  pepsin  prepared  by  Mr.  Kress,  of  Fifty-second 
Street  and  BroadAvay,  in  the  treatment  of  typhoid  fever.  One  ounce 
of  the  liquid  contains  30  min.  of  the  dilute  acid,  and  one  teaspoonful 
can  be  given  ever}^  third  hour  to  a  patient  of  five  years.  The  scanty 
secretion  of  gastric  juices  in  this  disease,  the  poor  ajjpetite  and  sIoav 
digestion,  indicate  the  need  of  such  medicine,  and  thus  far  the  result  has 
been  good. 

If  the  pulse  be  rapid  and  Aveak,  or  fluctuating,  digitalis  meets  the 
special  indication,  and  it  can  be  administered  Avith  or  betAveen  the  doses 


TIIEATMEXT,  357 

of  quinine.  As  there  is  great  proneness  to  diarrhoea  and  intestinal 
ulceration,  the  selection  of  the  proper  diet  is  important,  and  of  all  the 
dietetic  articles  milk  is  the  one  upon  -svliich  we  must  chiefly  rely  for  the 
sustenance  of  the  patient.  While  it  contains  the  desired  nutriment  it 
is  easy  of  digestion,  and  possesses,  Avhen  fresh  and  of  good  quality,  no 
irritating  property  Avhich  would  aggravate  the  intestinal  disease.  The 
meat  broths  or  juices,  fresh  eggs  beaten  up  in  milk,  farinaceous  foods,  as 
barley,  wheat,  or  rice  flour  in  the  milk,  are  proper  adjuvants  to  the  milk 
diet.  The  dry  state  of  the  mouth,  and  scanty  secretion  of  saliva,  and 
probably  also  of  the  pancreatic  juice  b}''  which  starch  is  digested,  show, 
however,  that  only  a  moderate  amount  of  flirinaceous  food  can  be  assim- 
ilated during  the  fever.  The  patient  may  be  allowed  to  drink  cold 
water  in  moderate  quantity. 

Mild  cases  of  typhoid  fever  do  not  require  alcoholic  stimulants,  but 
they  are  usefu.l  in  severe  cases  in  the  form  of  wine  whey  or  milk  punch, 
especially  in  the  third  and  fourth  weeks,  and  during  convalescence. 
When  the  pulse  is  feeble  and  quick,  the  mind  wandering,  and  the  fingers 
treuiulous,  the  regular  and  iudicious  use  of  alcohol  aids  materiallv  in 
sustaining  the  vital  })Owers  during  the  critical  period. 

The  complications  which  may  arise  in  the  course  of  the  fever  ret^uire 
prompt  treatment.  For  diarrhoea  opium  and  bismuth  are  needed;  for 
intestinal  hemorrhaore  an  ice  bao;  over  the  ridit  iliac  refrion,  and  intern- 
ally  opium  with  acetate  of  lead,  or  with  a  large  dose  of  sulmitrate  of 
bismuth,  or  small  and  repeated  doses  of  turpentine.  A  one-grain  ergotine 
pill  every  fourth  hour  to  a  child  of  eight  years,  also  aids  in  arresting 
the  hemorrhage.  But  intestinal  hemorrhage  as  a  result  of  typhoid 
ulcerations  is  much  more  rare  in  children  than  in  adults.  Bronchitis 
an<l  pneumonia  require  mildly  irritating  poultices,  with  the  oil-silk 
jacket. 

Tyjihoid  fever  may  relapse,  but  the  second  attack  is  commonly  milder 
than  the  first.  Nevertheless  on  account  of  the  liability  to  its  return, 
the  patient  should  be  quiet  and  free  from  perturbating  influences  during 
convalescence. 

To  guard  against  the  spread  of  the  disease,  the  stools  should  always 
be  promptly  disinfected,  by  adding  to  the  night-stool  carbolic  acid  and 
a  solution  of  the  sulphate  of  iron,  or  a  solution  of  the  chlorides,  and  all 
soiled  linen  should  be  ])laced  in  boiling  water. 


358  CEREBRO-SPINAL    FEVER. 


CHAPTER  lY. 

CEREBROSPINAL  FEVER. 

Several  years  ago,  before  New  York  physicians  had  any  personal 
experience  with  cerebro-spinal  fever,  an  outbreak  of  it  of  moderate 
extent  occurred  at  or  near  Long  Branch,  and  from  its  proximity, 
phj'sicians  were  apprehensive  that  it  miglit  enter  New  York.  Very 
interesting  discussions  consequently  took  place  in  the  Academy  of  Medi- 
cine concerning  the  cause  and  nature  of  this  malady,  and  theories  crude 
and  unfounded,  in  consequence  of  inexperience,  were  then  expressed. 
Unfortunately  the  fears  of  physicians  wiio  participated  in  that  discus- 
sion have  been  realized.  The  disease  entered  this  city  in  the  autumn 
of  1871,  appearing  first  among  the  horses  of  the  large  stables  of  the 
stage  and  car  lines,  disabling  and  destroying  many  of  them.  In 
December,  1871,  it  commenced  among  the  people,  and  since  that  time 
it  has  not  been  absent  from  the  city.  Its  unknown  cause,  which  in 
country  towns  soon  dies  out  or  becomes  inoperative,  from  lack  of  the 
conditions  Avliich  sustain  and  perpetuate  it,  finds  in  this  great  assem- 
blage of  people,  and  in  the  state  of  the  streets  and  domiciles,  the 
conditions  favorable  for  its  development  and  sustenance,  so  that  cerebro- 
spinal fever  is  now  fully  established  with  us.  It  has  become  one  of  the 
scourges  of  childhood,  destroying  many  lives  each  year,  and  injuring 
irreparably,  by  deafness  or  in  other  ways,  many  who  recover.  AVe  are 
noAV  much  better  prepared,  by  sad  experience,  to  discuss  this  disease 
than  were  those  physicians  wlio  participated  in  the  debates  alluded  to 
above. 

Etiology. — It  is  not  improbable,  from  the  clinical  history  of  cerebro- 
spinal fever,  and  from  recent  discoveries  touching  the  parasitic  origin 
of  several  of  the  common  constitutional  maladies,  that  the  obscure  and 
mysterious  cause  of  cerebro-spinal  fever  will  yet  be  discovered  by  mi- 
croscopical and  clinical  research.  Leyden,  indeed,  has  published  in  a 
recent  issue  of  the  Cent.  f.  Klin.  Med.,  p.  61,  a  paper  on  the  micro- 
coccus of  cerebro-spinal  meningitis,  and  M.  Ernest  Gandier'  states  that 
he  has  discovered  in  the  blood  and  urine  of  a  patient,  examined  fresh 
.  and  Avitli  "antiseptic  precautions,"  micrococci  in  great  abundance.  But 
proof  is  lacking  tliat  these  micrococci  sustain  a  causative  relation  to 
the  disease. 

At  the  debates  in  the  Academy  the  question  was  raised  whether  the 
cause  might  not  reside  in  the  cereals  or  some  other  agricultural  products. 
This  is  improbable,  for  of  two  adjacent  localities,  in  which  the  diet  of  the 
inhabitants  is  the  same,  one  escapes  and  the  other  is  visited  by  the 
epidemic.  The  disease  ceases  after  a  time,  although  the  food  of  the 
people  remains   unchanged.      Infants   at  the   breast  having  only   the 

1  Rev.  MedicHle,  June  3,  1882;  New  York  Medical  Record,  September  9,  1882. 


ETIOLOGY. 


359 


motiier's  milk  are  sometimes  affected,  and  likewise  certain  animals 
Avhose  food  is  very  different  from  that  of  man,  and  finally  the  most 
careful  examinations  have  hitherto  fiiiled  to  discover  any  dietetic  cause 
of  the  malady.  That  the  cause  does  not  emanate  from  the  soil,  directly 
at  least,  is  probable  from  the  fact  that  many  epidemics  commence  in  the 
■winter  Avhen  the  ground  is  frozen,  and  that  they  occur  in  localities  Avhere 
there  is  every  kind  of  soil  and  the  most  diverse  geological  formations. 
Probably,  therefore,  the  cause,  Avhatever  its  origin  and  nature,  resides 
in  the  atmosphere,  and  enters  the  system  through  those  channels  which 
receive  air.  Prof  Wm.  H.  Welch  writes  to  me  on  this  subject: 
''  Worthy  of  consideration,  though  unproven,  is  the  view  of  jNIedin,  that 
the  infectious  material  is  absorbed  by  the  lymph-spaces  of  the  nasal 
mucous  membrane,  Avhich,  according  to  Key  and  Retzius,  communicate 
on  the  one  side  with  the  atmosphere  through  openings  between  the  epi- 
thelial cells,  and  on  the  other  side  Avitli  the  subarachnoid  spaces  at  the 
base  of  the  brain." 

Among  the  con<lit:ons  which  are  favorable  for  the  occurrence  of  cere- 
bro-spinai  fever,  and  may  therefore  be  regarded  as  predisposing  to  it, 

Fig.  25. 


we  may  mention  the  Avinter  sea,=ion.  Statistics  collected  in  Europe 
and  the  United  States  show  thnt  while  166  epidemics  occurred  in 
the  six  months  commencing  with  December,  only  50  were  in  the 
remaining  six  montiis  of  the  year.  According  to  the  statistics  of  Prof. 
Ilirsch,  which  were  collected  mainly  from  Central  Europe,  57  cpidem'.cs 
were  in  winter  or  winter  and  spring,  11  in  s))ring,  5  between  sj^ring  and 
autumn,  4  commenced  in  autumn  and  extended  into  winter,  or  into  winter 
and  the  ensuing  spring,  and  6  lasted  the  entire  year.  I  suspect  that  the 
opinion  expressed  by  Prof  Ilirsch  is  correct,  that  the  excess  of  epi- 
demics in  the  winter  months  is  due  mainly  to  the  greater  crowding  ami 
less  ventilation  in  the  domiciles  durinir  the  cold  th:in  warm  months, 
especially  among  European  peasantry.  In  New  York  City,  Avhcre  the 
state  of  the  domiciles  is  about  the  same  the  year  round,  the  season 
aj)pears  to  exert  little  influence  on  the  prevalence  of  the  disease. 

All  observers  have  remarked  the  fact  that  anti-hygienic  comlitions 
increase  the  liability  to  cerebro-spinal  fever ;   in  other  words,  produce 


8C0  CEREBRO-S PINAL    FEVER. 

such  a  state  of  system  that  it  more  readily  yields  to  the  morbific  influ 
ence  and  contracts  the  malady.  Hence  soldiers  in  barracks  and  the 
poor  in  tenement  houses  suffer  most  severely  Avhen  the  epidemic  is  pre- 
vailing. In  New  York  City  the  fict  is  often  reuiarked  that  multiple 
cases  occur  for  the  most  part  ■where  obvious  unsanitary  conditions  exist, 
as  in  apartments  which  are  unusually  crowded  and  hlthy,  or  in  tene- 
ment-houses around  which  refuse  matter  has  collected,  or  Avhich  have 
defective  drainage.  The  interesting  chart  prepared  under  the  direction 
of  Dr.  Moreau  Morris  for  the  Health  Board,  shows  that  comparatively 
few  cases  occurred  in  the  epidemic  of  1872  in  those  portions  of  the  city 
where  the  sanitary  conditions  were  good.  Anti-hygienic  conditions  prob- 
ably predispose  to  cerebro-spinal  fever  in  the  same  way  that  they  do  to 
other  grave  epidemic  disease,  as,  for  example,  to  Asiatic  cholera,  whose 
ravages  are  chiefly  where  hygienic  requirements  are  most  neglected. 
We  will  presently  relate  striking  examples  which  show  how  foul  air 
increases  the  number  and  malignancy  of  cases. 

Is  Cerebfo-spinal  Fever  Contagious? — It  is  the  almost  unanimous 
opinion  of  those  who  are  most  competent  to  judge  from  their  observa- 
tions, that  it  is  either  not  contagious  or  is  contagious  in  only  a  slight 
degree.  It  is  certain  that  the  vast  majority  of  cases  occur  without  the 
possibility  of  personal  communication.  Thus,  in  the  commencement  of 
an  epidemic,  the  first  patients  are  affected  here  and  there,  at  a  distance 
from  each  other,  often  miles  apart,  and  throughout  an  epidemic,  usually 
only  one  is  seized  in  a  family.  Children  may  be  around  the  bedside  of 
the  patient,  passing  in  and  out  of  the  room  without  restriction,  and  yet 
Ave  can  confidently  predict  that  none  of  them  will  contract  the  malady, 
if  there  be  proper  ventilation  and  cleanliness,  and  none  of  the  conditions 
of  insalubrity  exist  within  or  around  the  domicile.  Moreover,  when 
multiple  cases  occur  in  a  family,  the  disease  begins  at  such  irregular 
intervals  in  the  different  patients,  that  there  can  be  little  doubt  in  most 
instances  that  it  is  not  communicated  from  one  to  the  other,  but,  like 
the  fevers  from  marsh  miasm,  is  produced  by  exposure  to  the  same 
morbific  cause,  existing  outside  the  individuals,  but  within  or  around 
the  premises.  Thus  in  the  Brown  family  treated  by  the  late  Dr.  John 
G.  Sewall,'  of  New  York.  The  first  child  sickened  January  3Uth,  and 
subsequently  the  remaining  five  children  at  intervals  respectively  of 
five,  seven,  eleven,  twenty-five,  and  forty-five  days.  That  so  many 
were  affected  in  one  family  was  attributed  by  the  doctor  to  the  filthy 
state  of  the  house  and  the  bad  })lumbing,  which  allowed  the  free  escape 
of  sewer-gas.  In  my  own  practice,  in  the  family  Avhich  suffered  the 
most  severely  of  all,  four  patients  were  seized  in  succession,  and  yet 
I  could  see  no  evidence  of  contagiousness.  '  The  fiimily  occupied  a 
small  plot  of  ground,  not  more  than  thirty  feet  by  one  hundred,  and 
their  occupation  was  to  prepare  for  the  meat-market  Avhat  is  known  as 
head-cheese.  They  lived  on  the  second  floor  of  the  two-story  wooden 
house  in  which  the  work  was  carried  on.  At  the  time  of  the  sickness 
the  shop  contained  four  hundred  heads  of  animals  from  Avliich  the 
meat  for  the  cheese  was  obtained,  and  evidently  more  or  less  decaying 
animal  matter  was  present.     The  occupation  and  surroundings  of  this 

1  Medical  Kecord,  July,  1872. 


ETIOLOGY.  361 

family  aiforded  sufficient  explanation  of  the  fact  that  so  many  were 
attacked.  Two  workmen  contracted  the  disease  within  about  one  week 
of  each  otiier,  and  were  removed  from  the  house.  Four  weeks  after  the 
commencement  of  the  malady  in  the  Avorkman  who  was  first  attacked, 
on  January  26th,  one  child  sickened  Avith  it,  and  died  on  February  1st. 
Fifteen  days  subsequently  (February  16th)  a  second  child  was  attacked 
by  it,  and  after  a  tedious  sickness  finally  recovered.  The  long  and 
irregular  intervals  between  these  cases  indicate  that  the  disease  was  not 
contracted  by  one  from  the  other.  The  important  factor  in  causing  so 
severe  an  outbreak  of  cerebro-spinal  fever  in  this  family  Avas  probably 
tlie  miasm  produced  by  such  an  occupation  in  the  house  Avhere  the 
family  resided,  Avitli  neglect  of  \'entilation  and  cleanliness. 

But  tlie  strongest  evidence  that  cerebro  spinal  fcA'er  is  either  non- 
contagious, or  very  feebly  contagious,  is  afforded  by  the  fact  that  a 
large  majority  of  the  cases  occur  singly  in  families,  although  there  is 
no  isolation  of  tlie  patients.  Tlie  foUoAving  are  the  statistics  relating  to 
this  point  of  the  cases  Avhich  I  have  observed  since  cerebro-spinal  fever 
commenced  in  Ncav  York,  in  1871 :  Single  cases  occurred  in  scA^enty 
families;  dual  cases  occurred  in  nine  families;  three  cases  occurred  in 
one  family,  and  four  cases  in  one  family.  Intercourse  Avith  the  sick- 
room Avas  unrestricted  in  all  these  families,  so  that  children  frequently 
Avent  out  and  in,  and  sometimes  assisted  in  the  nursing. 

The  most  striking  example  of  apparent  contagiousness  Avhich  has 
come  to  my  knowledge  Avas  related  by  Hirsch,  and  is  quoted  by  von 
Ziemssen.  A  young  man  sickened  Avitli  cerebro-spinal  fever  on  Feb- 
ruary 8th.  The  Avoman  Avho  nursed  him  returned  to  her  home  in  a 
neighboring  village  and  there  died  of  the  same  disease  on  February  26th. 
To  her  funeral  mourners  came  fiom  a  neighboring  township,  and  after 
their  return  liome  three  of  them  died  Avith  the  same  disease,  one  Avithin 
twenty-four  hours,  another  on  March  4th,  and  a  third  on  the  7th. 

In  one  instance  only  in  my  practice  did  the  facts  point  to  contagious- 
ness. A  boy  of  twelve  years  died  of  cerebro-spinal  fever  an(i  Avas  buried 
on  Saturday  or  Sunday.  On  Monday  the  mother  Avashed  the  linen  and 
bedclothes  of  the  boy,  Avhich  had  accumulated  and  Avere  in  a  very  filthy 
state.  Two  days  subsequently  she  Avas  attacked,  and  her  infant  soon 
afterward,  both  perishing.  The  state  of  the  bedding  and  apartments 
in  this  house,  as  seen  Ity  myself,  Avas  such  as  Avould  be  likely  to  concen- 
trate and  intensify  the  poison,  rendering  it  peculiarly  active,  for  they 
Avere  very  dirty,  and  the  mother,  exhausted  by  her  long  and  incessant 
watching  and  hick  of  sleep,  and  depressed  by  grief,  rendered  her  system 
more  liable  to  the  disease  by  her  self-imposed  duties  on  the  day  after  the 
funeral.  One  in  her  state  of  mind  and  body,  standing  f  )r  a  consider- 
able part  of  a  day  over  the  bedclothes  and  bedding  of  her  child,  foiled 
by  the  excreta,  Avould  certainly  be  in  a  condition  to  contract  the  disease 
if  it  were  in  anv,  even  in  the  lowest  dejirei",  contagious.  In  the  iiresent 
state  of  our  knowledge,  therefore,  \i\)o\\  this  important  subject,  the  evi- 
dence leads  us  to  believe  that  Avitli  proper  A'cntilation  and  cleanliness, 
and  the  sup|)ression  of  anti-hygienic  conditions  in  an  infected  domicile, 
those  Avho  are  in  a  good  state  of  body  and  mind  Avill  not  contract  the 


362  CEREBRO-SPINAL    FEVER. 

disease,  but  in  the  opposite  conditions  it  is  not  improbable  that  tht 
poison  may  be  so  intensified,  and  the  system  rendered  so  liable  to  receive 
the  prevailing  malady,  through  impairment  of  the  general  health  and 
diminished  resisting  power,  that  cerebro-spinal  fever  may,  though  rarely, 
be  communicated  either  by  the  breath  of  the  patient,  or  by  exhalations 
from  his  surface,  or  from  soiled  clothing.  If  so,  it  of  course  possesses  a 
low  decree  of  contagiousness. 

The  occurrence  of  cerebro-spinal  fever  in  certain  of  the  lower  animals 
is  a  very  interesting  fact,  especially  as  the  question  is  sometimes  asked 
whether  it  may  not  be  communicated  from  them  to  man.  In  the  epi- 
demic of  1811  in  Vermont,  according  to  Dr.  Gallop,  even  the  foxes 
seemed  to  be  aflfected,  so  that  they  Avere  killed  in  numbers  near  the 
dwellings  of  the  inhabitants.  Cerebro-spinal  fever,  previously  unknown 
in  New  York  City,  began,  as  stated  above,  in  1871,  among  the  horses 
in  the  large  stables  of  the  city  car  and  stage  lines,  disabling  many  and 
proving  very  fatal,  while  among  the  people  the  epidemic  did  not  properly 
commence  till  January,  1872,  although  a  few  isolated  cases  occurred  in 
December  of  1871.  No  evidence  exists,  so  far  as  I  am  aware,  that  the 
disease  was,  in  any  instance,  communicated  by  these  animals  to  man. 
Those  who  had  charge  of  the  infected  horses,  as  the  veterinary  surgeons 
and  stablemen,  did  not  contract  the  malady,  certainly  not  more  frequently 
than  others  who  were  not  so  exposed.  Although  we  may  admit  slight 
contagiousness,  there  has  probably  been  no  well-established  example  of 
the  transmission  of  cerebro-spinal  fever  from  animals  to  man.  If  trans- 
mission ever  does  occur,  it  is  so  rare  that  practically  no  account  need  be 
made  of  it. 

In  some  instances  we  are  able  to  discover  an  exciting  cause.  An 
individual  whose  system  is  affected  by  the  epidemic  influence,  may 
perhaps  escape  by  a  quiet  and  regular  mode  of  life,  but  if  there  be  any 
unusual  excitement,  or  the  normal  functional  activity  of  the  system  be 
seriously  disturbed,  an  outbreak  of  the  malady  may  occur.  Among  the 
exciting  causes  we  may  mention  over-work  and  lack  of  sleep,  fjitigue, 
mental  excitement,  depressing  emotions,  prolonged  a1)stinence  from  food 
followed  by  over-eating,  and  the  use  of  indigestible  and  improper  food. 
Thus  in  one  instance  among  my  cases,  a  delicate  young  woman,  at  the 
head  of  one  of  the  departments  in  a  well-known  Broadway  store,  was 
anxious  and  excited,  and  her  energies  overtaxed,  at  the  annual  reopen- 
ing. Within  a  day  or  two  subsequently  the  disease  began.  Another 
patient,  a  boy,  was  seized  after  a  day  of  unusual  excitement  and  exposure, 
having  in  the  meantime  bathed  in  the  Hudson  Avhen  the  weather  was 
quite  cool.  Those  children  have  seemed  to  me  especially  liable  to  be 
attacked  who  were  subjected  to  the  severe  discipline  of  the  public 
schools,  returning  home  fatigued  and  hungry  and  eating  heartily  at  a 
late  hour.  In  one  instance  which  I  observed,  a  school-girl,  ten  years 
of  age,  returned  from  school  excited  and  crying  because  slie  had  failed 
in  her  examination  and  had  not  been  promoted.  In  the  evening,  after 
she  had  closely  studied  her  lessons,  the  fever  began  with  violent  headache. 

Dr.  Frothingham^  writes  as  follows  of  the  brigade  in  which  cerebro- 

1  American  Medical  Times,  Ajjril  30,  18G4. 


SEX.  363 

spinal  fever  occurred  in  the  Anny  of  the  Potomac:  "Under  General 
Butterfield,  a  stern  disciplinarian,  .  .  .  the  men  were  drilled  to 
the  full  extent  of  their  powers,  often  to  exhaustion.  I  did  not  at  the 
time  recognize  this  as  the  cause  of  the  disease  in  question,  but  I  learnt 
that  in  the  present  epidemic  in  Pennsylvania  the  attack  generally  fol- 
lows unusual  exertion  and  exposure  to  cold." 

Many  observers  have  noticed  that  bodily  fatigue  and  mental  depres- 
sion and  excitement  are  important  factors  in  causing  an  attack  of  cerebro- 
spinal fever,  when  this  disease  is  epidemic.  Dr.  Gallop,  in  his  history 
of  cerebro-spinal  fever,  as  it  occurred  in  Vermont  in  1811,  directs 
attention  to  the  severity  of  the  cases  among  the  troops  under  General 
Dearborn,  who  were  fatigued  by  marches  and  greatly  dispirited  on 
account  of  a  repulse  which  they  had  just  sustained  from  the  British.  In 
one  case,  which  occurred  in  my  practice,  a  boy,  six  years  and  eleven 
months  of  age,  Avas  punished  at  school  and  came  home  with  cheeks 
flushed  from  excitement,  the  excitement  continuino-  during  the  ensuing; 
night.  On  the  following  dav  cerebro-spinal  fever  began  Avith  vomiting 
and  chilliness,  the  attack  ending  fatally  on  the  seventeenth  day.  In  an- 
other case,  which  Avas  related  to  me  by  the  mother  and  the  physician,  the 
patient,  a  bright  girl,  twelve  years  of  age,  of  nervous  temperament,  and 
forward  in  her  studies,  had  been  nmch  excited  in  competing  for  a  prize 
in  athletic  exercises.  In  the  evening  of  the  same  day  a  violent  thunder- 
storm  occurred,  and  after  a  severe  clap  she  started  from  bed,  ])allid  and 
excited,  and  expressed  the  belief  that  she  had  been  struck  by  lightning. 
The  disease  began  immediately  after  this,  and  terminated  fajally  on  the 
fifth  day. 

Skx. — It  is  stated  by  certain  writers  that  more  males  are  aifected 
than  fenuiles.  The  statistics  of  hospitals  and  cam])s  show  this  ;  for  men 
subject  to  lives  of  hardship  arc  especially  liable  to  be  attacked,  but  in 
family  |)ractice,  in  Avhich  a  large  jtroportioti  of  the  patients  are  "hildren, 
the  number  of  males  and  females  is  about  equal.  Thus  in  105  cases, 
occurring  chiefly  in  my  practice,  but  a  few  of  them  in  the  practice  of  two 
other  physicians  of  this  city,  I  find  that  5i)  Avere  nudes  and  4()  females. 
Ninety-one  of  these  Avere  children.  In  New  York  City,  during  the 
epidemic  of  1872,  905  cases  of  cerebro-spinal  fever  Avere  re|)()rted  to 
the  Health  Board  betAveen  January  1st  and  November  1st,  and  of  these 
484  Avere  males  and  421  females.  Dr.  Sanderson's  statistics  of  the 
epidemic  in  the  provinces  around  the  Vistula,  the  cases  being  chiefly 
children,  give  also  but  a  slight  excess  of  males.  Probably,  therefore,  in 
the  same  conditions  and  occupations  of  life  the  sexes  are  e([ually  liable 
to  contract  this  malady,  and  the  excess  of  males  is  due  to  the  fact  that 
they  lead  a  more  irregular  life,  and  are  more  subject  to  privations  and 
exposures.  That  soldiers  on  duty  or  in  barracks  have  been  attacked 
Avhile  families  in  the  vicinity  escape,  thus  increasing  the  ])roportion  of 
male  cases,  must  be  due  to  irregularities,  hardships,  and  perhaps  the 
lack  of  sanitary  rcgulatioiis  in  th<.'  mode  of  their  life. 

AiiK. — ('hildrcii,  as  already  stated,  are  nuich  more  apt  to  contract 
cerebro-spinal  fever  than  adults.  The  folloAving  are  the  statistics  (»f  the 
N.  Y.  Health  Board  relating  to  the  age  of  the  cases  during  the  epidemic 
of  1872 : 


36-i  CEREBRO-SPINAL    FEVER. 

Under  1  year        .  .         .         .         .         .         .         .         .         .125 

From    1  to    5  years 336 

From    5  to  10  "  . 204 

From  10  to  15  " 106 

From  15  to  20  "  .         .         . 54 

From  20  to  30  " 79 

Over   30  years 71 

Total 975 

In  the  cases  which  occurred  in  mj  own  practice,  and  in  a  few  cases 
in  the  practice  of  other  ph^^sicians  added  to  mine,  I  find  that  the  ages 
were  as  follows: 

Under  1  year        ..........  16 

From    1  to    3  years 27 

From    3  to    5     " 25 

From    5  to  10     " 20 

From  10  to  15     " 10 

Over   15  years       ..........  15 

Total 113 

In  my  practice,  therefore,  three-fourths  of  the  cases  have  been  under 
the  age  of  ten  years,  and  the  statistics  of  epidemics  in  other  localities 
correspond  Avith  mine  in  giving  a  large  excess  of  cases  in  childhood. 
Thus  Dr.  Sanderson,  in  exannning  the  records  of  deaths  in  one  epi- 
demic ascertained  that  two  hundred  and  eighteen  had  perished  under 
the  age  of  fourteen  years,  and  only  seventeen  above  that  age ;  and 
althoucrh  tlus  does  not  show  the  exact  ratio  of  children  to  adults  in  the 
entire  number  of  cases,  it  is  evident  that  the  children  were  greatly  in 
excess. 

The  more  advanced  the  age  after  the  tenth  year,  the  less  the  liability 
to  this  malady,  so  that  very  few  who  have  passed  the  thirty-fifth  year 
are  attacked,  and  old  age  possesses  nearly  an  immunity.  In  New  York 
City,  in  which,  as  we  have  seen,  cerebro-spinal  fever  has  been  occurring 
since  ISTl,  only  two  cases  have  come  to  my  knowledge  Avhich  had 
passed  the  fortieth  year.  The  age  of  one  was  forty -seven,  and  the  other 
sixty-three  years. 

Symptoms. — During  the  prevalence  of  cerebro-spinal  fever  cases  now 
and  then  occur  in  which  the  symptoms  are  mild  and  transient,  and  the 
health  is  soon  fully  restored.  It  seems  proper  to  regard  some,  at  least, 
of  these  as  genuine  but  aborted  forms  of  tlie  disease.  The  following 
cases  which  occurred  in  my  practice  may  be  cited  as  examples: 

A  boy,  eight  years  of  age,  previously  well,  was  taken  witli  headache, 
vomiting,  and  moderate  febrile  movement,  on  April  2,  1872.  The  evacua- 
tions were  regular  and  n(j  local  cause  of  the  attack  could  be  discovered. 
On  the  following  day  the  symptoms  continued,  except  the  vomiting,  but 
he  seemed  somewhat  better.  On  April  4th  the  febrile  mo\en)eut  was 
more  pronounced,  and  in  the  afternoon  he  was  drowsy  and  had  a  slight 
convulsion.  The  forward  movement  of  the  head  was  ap])arently  some- 
what restrained.  On  the  6th  the  symptoms  had  begun  to  abate,  and  in 
about  one  week  from  the  commencement  of  the  attack  his  health  was  fully 
restored. 

A  boy,  aged  six,  was  well  till  the  second  week  in  May,  1872,  when  he 


MODE    OF    COMMEXCEMENT.  oQo 

became  feverish  and  complained  of  headache.  At  my  first  visit,  on  ^lay 
14th,  he  still  had  headache,  with  a  {niUe  of  112.  The  pupils  were  sen- 
sitive to  light,  but  the  right  pupil  was  larger  than  the  left.  The  bromide 
and  iodide  of  potassium  were  ])rescribed.  with  moderate  counter-irritation 
behind  the  ears.  The  headache  and  febrile  movement  in  a  few  days 
abated,  the  equality  of  the  pupils  was  restored,  and  within  a  little  more 
than  one  week  from  the  commencement  of  the  disease  he  fully  recovered. 

These  cases  occurred  when  the  epidemic  of  1872  was  at  its  height ; 
but  if  the  symptoms  are  so  mild,  antl  the  duration  of  the  disease  short, 
as  in  these  two  cases,  the  diagnosis  must  sometimes  be  doubtful.  Ob- 
servers in  different  epidemics  report  similar  cases,  and  as  the  s^nnptoms, 
so  far  as  they  appeared  in  my  patients,  si'caied  characteristic,  I  have 
not  hesitated  to  regard  them  as  genuine  but  aborted  cases.  On  such 
patients  the  epidemic  influence  acts  so  feebly,  or  their  ability  to  resist  it 
is  so  great,  that  they  escape  with  a  short  and  trivial  ailment. 

Occasionally,  also,  during  the  progress  of  ^an  epidemic,  "we  meet 
patients  who  present  more  or  fewer  of  the  characteristic  symptoms,  but 
in  so  mild  a  form  that  they  are  never  seriously  sick,  and  never  entirely 
lo.se  their  appetite,  but  the  disease,  instead  of  aborting,  continues  about 
the  usual  time. 

Thus,  on  Januai-y  4,  1873,  I  Avas  called  to  a  girl  aged  thirteen,  who 
had  been  seized  with  headache  followed  by  vomiting  in  the  last  week  in 
December.  During  a  period  of  six  to  eight  weeks,  or  till  nearly  March 
1st,  she  had  the  following  symptoms  :  Daily  paroxysmal  headache,  often 
most  severe  in  the  forenoon ;  neuralgic  pain  in  the  left  hypochondrium, 
and  sometimes  in  the  e])igastric  region  ;  pulse  and  temperature  some- 
times nearly  normal,  and  at  other  times  accelerated  and  elevated,  both 
with  daily  variations ;  incrpialit}'  of  the  pupils,  the  right  being  larger 
than  the  left  during  a  portion  of  the  sickness.  The  patient  was  never 
so  ill  as  to  keep  the  bed,  usually  sitting  quietly  during  the  day  in  a 
chair  or  reclining  on  a  lounge,  and  she  never  fully  lost  her  appetite. 
Quinine  had  no  appreciable  effect  on  the  fever  or  paroxysms  of  pain. 
There  can,  in  my  opinion,  be  little  doubt  that  this  girl  was  aflected  by 
the  ej)idemic,  but  so  mildly  that  there  was,  for  a  considerable  time, 
much  uncertainty  in  the  diagnosis. 

Ca.ses  like  these,  in  which  the  disease  is  so  feebly  developed  that  the 
patient  is  never  seriously  sick,  though  unimportant  pathologically,  must 
be  recognized  in  a  treatise  on  cerebro-sj)inal  fever. 

Modi-:  of  Commknckmkxt. — Cerebro-sjjinal  fever  rarely  begins  in  the 
forenoon  after  a  night  of  ([uict  and  sound  sleep.  In  the  cases  which  T 
observed  in  the  severe  and  fatal  epidemic  of  l''^72,  and  in  the  thirty-six 
cases  of  which  I  have  records  observed  since  1872,  the  commencement 
was  almost  without  exception  between  mid-day  and  midnight.  The 
fact  that  this  disease  does  not  commence  after  the  repose  of  night,  till 
several  hours  of  the  day  have  passed,  shows  the  propriety  and  neeil  df 
enjoining  a  rpiict  and  regular  mode  of  life,  free  from  excitement,  and 
with  sufficient  hours  of  sleep,  during  the  time  in  which  the  epiilemic  is 
prevailing. 

The  commencement  is  usually  without  premonitory  stage,  and  sudden; 
unlike,  therefore,  the  beginning  of  other  forms  of  meningitis,  which  come 


366  CEREBRO-SPIXAL    FEVER. 

on  gradually  and  are  preceded  by  symptoms  which,  if  rightly  interpreted, 
direct  attention  to  the  cerebro-spinal  system.  Exceptionally  certain 
premonitions  occur  for  a  few  hours  or  days  before  the  advent  of  the 
disease,  such  as  languor,  chilliness,  etc.  Mild  cases  more  frequently 
begin  gradually,  and  with  certain  premonitions,  than  severe  cases.  The 
ordinary  mode  of  commencement  is  as  folloAvs :  The  patient  is  seized 
with  vomiting,  headache,  and  perhaps  a  chill  or  chilliness,  so  that  there  is 
a  sudden  change  from  perfect  health  to  a  state  of  serious  sickness.  Rigor 
or  chilliness  is  a  common  initial  symptom,  especially  in  adult  patients. 
One  patient,  an  adult  female,  had  three  or  four  chills  of  considerable 
severity  in  the  commencement  of  the  attack.  Children  often  have 
clonic  convulsions  in  place  of  the  chill,  or  immediately  after  it,  partial 
or  general,  slight  or  severe.  Stupor  more  or  less  profound,  or  less  fre- 
quently delirium  succeeds.  In  the  gravest  cases  semi-coma  occurs 
within  the  first  few  hours,  in  which  patients  are  with  difficulty  aroused, 
or  profound  coma,  which,  in  spite  of  prompt  and  appropriate  treatment, 
is  speedily  fatal.  Those  thus  stricken  down  by  the  violent  onset  of  the 
disease,  if  aroused  to  consciousness,  complain  of  severe  headache,  with 
or  without,  or  alternating  Avith  equally  severe  neuralgic  pains  in  some 
part  of  the  trunk,  or  in  one  of  the  extremities.  The  pain  frequently 
shifts  from  one  part  to  another.  Among  the  early  symptoms  of  cerebro- 
spinal fever  are  those  which  pertain  to  the  eye.  The  pupils  are  dilated, 
or  less  frequently  contracted,  and  they  respond  feebly,  or  not  at  all, 
to  light  if  the  attack  be  severe  and  dangerous  ;  often  they  oscillate,  and 
occasionally  one  is  larger  than  tlic  other.  A'^omiting  witli  little  apparent 
nausea,  and  often  projectile,  is  common  in  the  commencement  of  cerebro- 
spinal fever.  It  occurred  as  an  early  symptom  in  fifty-one  of  fifty-six 
cases  observed  by  Dr.  Sanderson.  In  ninty-seven  cases  occurring  in 
New  York,  most  of  them  observed  by  myself,  but  a  few  of  them  related 
to  me  by  the  late  Dr.  John  G.  SeAvall,  vomiting  occurred  as  an  early 
symptom  in  sixty-eight  cases.  Its  absence  on  the  first  day  was  recorded 
in  only  three  cases,  while  in  the  remaining  twenty-seven  patients  the 
records  of  the  first  day  make  no  mention  of  its  presence  or  absence. 
It  was  probably  present  in  most  of  these  twenty-seven  cases  as  one  of 
the  first  symptoms. 

Since  the  epidemic  of  1872,  in  examining  patients  now  numbering 
thirty-six,  as  has  been  already  stated,  I  have  made  careful  in(juiry  in 
regard  to  the  mode  of  commencement,  and  Avith  only  tAvo  or  three  excep- 
tions the  previous  health  had  either  been  good,  or  if  symptoms  of  ill- 
health  antedated  the  cerebro-spinal  fever,  they  were  due  to  some  ailment 
entirely  distinct  from  this  disease.  In  a  boy  four  and  a  half  years  of 
age,  living  in  Broadway,  it  Avas  stated  to  me  that  the  cerebro-spinal  fever 
came  on  gradually,  'with  pains  in  the  head  and  elseAvhere;  this  case  Avas 
mild  throughout,  and  the  patient  Avas  never  in  imminent  danger.  In 
nearly  all  the;  cases,  if  the  patients  Avere  at  home  and  under  obserA'ation, 
the  exact  moment  of  the  beginning  of  the  disease  could  be  stated.  Thus 
a  man  aged  tAventy-eight  returned  from  his  Avork  at  midday,  April  23, 
1883,  in  good  health  and  cheerful,  ate  a  hearty  meal  at  12  M.  and  at  1 
p.  M.  had  a  chill,  Avith  intense  headache  and  severe  vomiting.  Minute  red 
points  appeared  on  his  face  after  the  vomiting  from  capillary  extra vasa- 


SYMPTOMS.  367 

tions.  In  this  case  the  interesting  fact  was  observed  of  a  cessation  of  the 
symptoms,  so  that  on  the  24th  and  2oth,  being  free  from  pain,  lie  Avent 
to  Brooklyn.  On  the  26th,  however,  the  symptoms  returned.  He  had 
pains  in  the  head,  back,  and  extremities,  and  was  seriously  sick.  Occa- 
sional remissions,  so  that  very  grave  symptoms  become  mild  for  a  time, 
and  then  return  in  full  severity,  as  well  as  distinct  intermissions  as  in 
this  case,  have  been  frequently  noticed  by  observers  in  difierent  epi- 
demics. A  little  girl,  previously  entirely  well,  was  slightly  punished 
on  June  11,  18*:i2 ;  immediately  she  vomited,  and  seemed  quite  sick  ; 
by  kind  nursing  on  the  part  of  the  mother  she  became  better,  so  that  on 
the  12th  she  had  some  appetite  and  went  out.  On  the  13th,  cerebro- 
spinal fever  began,  with  a  temperature  of  103°,  and  its  course  was  tedious. 
A  robust  girl,  aged  thirteen,  vivacious  and  cheerful,  went  as  usual  in  the 
morning  to  one  of  the  public  schools,  entirely  well.  Before  the  school 
was  dismissed  she  returned  home  crying,  on  account  of  dizziness  and 
violent  pain  on  the  top  of  her  head,  in  her  knees,  and  calves  of  the  legs. 
The  case  was  attended  by  Professors  Alonzo  Clark,  Knapp,  and  myself, 
and  was  fatal  after  four  and  a  half  weeks.  A  boy,  aged  ten,  returned 
from  another  public  school  in  a  similar  manner,  having  gone  to  it  in  the 
morning  in  apparent  perfect  health. 

We  may,  therefore,  summarize  as  follows  the  symptoms  which  com- 
monly attend  the  commencement  of  cerebro-spinal  fever:  violent  pain 
in  some  part  of  the  head,  and  sometimes  also  in  the  trunk  or  limbs, 
vomiting,  a  chill  or  chilliness,  clonic  convulsions,  dizziness,  dilated,  slug- 
gish, or  altered  pupils,  fever  of  greater  or  less  intensity  according  to  the 
severity  of  the  attack,  heat  of  head,  and  in  most  patients  of  the  surface 
generally.  If  the  disease  be  of  a  severe  and  dangerous  type  these  symp- 
toms are  frecjuently  followed  within  a  few  hours  by  delirium,  semi-coma, 
or  coma. 

Symptoms.  Nervous  System. — Since  in  cerebro-spinal  fever  ex- 
tensive and  intense  inflammation  occurs  of  the  cerebral  and  spinal  men- 
inges, with  more  or  less  congestion  of  the  brain  and  sjiituil  cord,  lesions 
which  we  will  consider  hereafter,  we  would  expect  that  this  disease  would 
be  attended  by  severe  and  dangerous  symptoms,  inasmuch  as  the  eerebro- 
spiruil  axis  exerts  such  a  controlling  influence  upon  the  functions  of  the 
body.  Also  wo  would  expect  that  the  symptoms  would  vary  according 
to  the  portion  of  the  meninges  which  happens  to  be  most  severely  in- 
flamed. There  is,  indeed,  vai'iation  in  symptoms  according  to  the  extent 
and  intensity  of  the  meningitis,  and  the  degree  in  which  the  cerebro- 
spinal axis  is  congested  or  implicated,  but  certain  symptoms  occur  in  all 
or  nearly  all  cases,  and  as  they  are  characteristic  they  render  diagnosis 
easy. 

Pain,  already  described  as  an  initial  symptom,  continues  during  the 
acute  ])eri<td  of  the  malady.  It  is  ordinarily  severe,  eliciting  moans 
from  the  sufterer,  but  its  intensity  varies  in  different  patients.  Its  most 
frecpient  seat  is  the  head,  and  the  location  of  the  cephahilgia  varies  in 
different  patients  and  in  the  same  patient  at  different  times.  One  refers 
it  to  the  top  of  the  head,  another  to  the  occiput,  and  anotiier  to  tlic 
frontal  region,  and  the  same  j)atient  at  different  times  may  complain  of 
all  these  parts.     The  i)ain  is  described  as  sharp,  lancinating,  or  boring. 


868  CEREBRO-SPINAL    FEVER, 

It  is  also  common  in  the  neck,  especially  in  the  nucha,  the  epi,2i;astrium, 
uml)ilical,  and  lumhar  regions,  along  the  spine  (rachialgia),  and  in  the 
extremities,  where  it  shifts  IVcmi  one  part  to  another.  It  is  more  common 
and  persistent  in  the  head  and  along  the  spine  than  elsewhere.  The 
patient,  it"  old  enough  to  speak,  and  not  delirious  or  too  stupid,  often 
exclaims,  "Oh  !  my  head,"  from  the  intensity  of  his  suffering,  but  after 
some  moments  complains  equally  of  pain  in  some  other  part,  while 
perhaps  the  headache  has  ceased  or  is  milder.  In  a  few  instances  the 
headache  is  absent,  or  is  slight  and  transient,  while  the  pain  is  severe 
elsewhere.  After  some  days  the  pain  begins  to  abate,  and  by  the  close 
of  the  second  week  is  much  less  pronounced  than  previously.  Vertigo 
occurs  with  the  headache,  so  that  the  patient  reels  in  attempting  to 
stand  or  walk.  I  have  stated  above  that  vertigo  may  be  a  prominent 
initial  symptom,  as  in  the  girl  of  thirteen  years,  Avho  suddenly  became 
sick  in  the  public  school  where  she  w^as  attending,  and  reached  her 
home  with  diificnlty  on  account  of  the  headache  and  dizziness.  Con- 
tributing to  the  unsteadiness  of  the  muscular  movements  is  a  notable 
loss  of  flesh  and  strength,  Avhich  occurs  early  and  increases. 

The  state  of  the  patients  mind  is  interesting.  It  is  Avell  expressed 
in  ordinary  cases  by  the  term  apathy  or  indifference,  and  between  this 
mental  state  and  coma  on  the  one  hand,  and  acute  delirium  on  the  other, 
there  is  every  grade  of  mental  disturbance.  Some  patients  seem  totally 
unconscious  of  the  words  or  presence  of  those  around  them,  when  it 
subsequently  appears  that  they  understood  what  was  said  or  done. 
Delirium  is  not  infrequent,  especially  in  the  oUler  children  and  adults. 
Its  form  is  various,  most  frequently  quiet  or  passive,  but  occasionally 
maniacal,  so  that  forcible  restraint  is  re(iuired.  It  sometimes  resembles 
intoxication  or  hysteria,  or  it  may  appear  as  a  simple  delusion  in  regard 
to  certain  subjects.  Thus  one  of  my  patients,  a  boy  of  five  years,  ap- 
peared for  the  most  part  rational,  protruding  his  tongue  when  requested, 
and  ordinarily  answering  questions  correctly,  but  he  constantly  mistook 
his  mother — who  w'as  always  at  his  bedside — for  another  person.  Severe 
active  delirium  is  commonly  preceded  by  intense  headache.  In  favora- 
ble cases  the  delirium  is  usually  short,  but  in  the  unfavorable  it  is  apt 
to  continue  with  little  abatement  till  coma  supervenes. 

On  account  of  the  pain  and  the  disordered  state  of  the  mind,  patients 
seldom  remain  quiet  in  bed  unless  they  are  comatose,  or  the  disease  be 
mild  or  so  far  advanced  that  muscular  movements  are  difficidt  from  weak- 
ness. In  severe  cases  they  are  ordinarily  quiet  for  a  fcAV  moments,  as 
if  slumbering,  and  then,  aroused  by  the  })ain,  they  roll  or  toss  from  one 
part  of  the  bed  to  another.  One  of  my  patients,  a  boy  of  five  years, 
repeatedly  made  the  entire  circuit  of  the  bed  during  the  spells  of  rest- 
lessness. In  mild  cases,  or  cases  attended  by  less  headache  or  mental 
disturl)ance,  patients  are  quiet,  usually  with  their  eyes  closed,  unless 
when  disturbed. 

Hyperesthesia  of  the  surfoce  is  another  common  symptom.  Few 
patients,  not  comato:ie,  are  free  from  it  during  the  first  weeks,  and  it 
materially  increases  the  suffering.  Friction  upon  the  surface,  and  even 
slight  pressure  with  the  fingers  upon  certain  parts  extort  cries.  Gently 
separating  the  eyelids  for  the  purpose  of  inspecting  the  eyes,  and  moving 


SYMPTOMS.  369 

the  limbs,  or  changing  the  position  of  the  head,  evidently  increase  the 
suffering,  and  are  resisted.  I  have  sometimes  heard  such  expressions 
of  suffering  from  slowly  introducing  the  thermometer  into  the  rectum 
that  I  Avas  led  to  believe  that  the  anal  and  perhaps  rectah surfaces  Avere 
hypersensitive.  The  hyperiesthesia  has  diagnostic  value,  for  there  is 
no  disease  with  Avhich  cerebro-spinal  fever  is  likely  to  be  confounded  in 
which  it  is  so  great.  It  is  due  to  the  spinal  meningitis,  and  is  appre- 
ciable even  in  a  state  of  semi-coma.  The  headache  and  hypenesthesia 
fluctuate  greatly  in  the  course  of  the  disease,  and  the  former  sometimes 
recurs  at  times,  especially  from  mental  excitement,  or  from  an  afHux  of 
blood  to  the  brain  from  physical  exertion,  for  months  after  the  health 
is  otherwise  fully  restored.  . 

Some  contraction  of  certain  muscles  or  groups  of  muscles  is  present 
in  all  typical  cases.  In  a  small  proportion  of  patients  it  is  absent  or  is 
not  a  prominent  symptom,  namely,  in  tliose  in  whom  the  encephalon  is 
mainly  involved,  the  spinal  cord  and  meninges  being  but  slightly  affected 
or  not  all.  This  contraction  is  most  marked  in  the  muscles  of  the  nucha, 
causing  retraction  of  the  head,  but  it  is  also  common  in  the  posterior 
muscles  of  the  trunk,  causing  opisthotonos,  and  in  less  degree  in  those 
of  the  abdomen  and  lower  extremities,  and  hence  the  flexed  position  of 
the  thighs  and  legs,  in  which  patients  obtain  most  relief.  The  muscular 
contraction  is  not  an  initial  symptom.  I  have  ordinarily  first  observed 
it  about  the  close  of  the  second  day,  but  sometimes  as  early  as  the  close 
of  the  first  day,  and  in  other  instances  not  till  the  close  of  the  third  day. 
Attempts  to  overcome  the  rigidity,  as  by  bringing  forward  the  head,  are 
very  painful,  and  cause  the  patient  to  resist.  In  young  children  having 
a  mild  form  of  the  fever,  with  little  retraction  of  the  head,  the  rigidity 
is  sometimes  not  easily  detected.  I  have  been  able  in  such  cases  to 
satisfy  myself  and  the  friends  of  its  presence,  by  placing  the  child  in  an 
upright  position,  as  on  the  lap  of  the  mother,  and  observing  the  difficulty 
with  which  the  head  is  brought  forward  on  ])resenting  to  the  patient  a 
tumblerful  of  cold  water,  which  is  craved  on  account  of  the  thirst.  The 
usual  ])osition  of  the  patient  in  IkmI,  in  a  typical  or  marked  case,  is  with 
the  head  thrown  back,  the  thighs  and  legs  flexed,  Avith  or  without 
forward  arching  of  the  spine.  Tlie  muscular  contraction  and  rigidity 
continue  from  three  to  five  weeks,  more  or  less,  and  abate  gradually; 
occasionally  they  continue  much  longer.  Through  the  kindness  of  Dr. 
Henry  Griswold  I  was  allowed  to  see  an  infant  of  seven  months  in  the 
tenth  week  of  tlie  disease.  It  was  still  vtn-y  frctrul,  and  exhibited  dt'cided 
]>rominence  of  the  anterior  fontanelle,  ])roi)al)ly  from  intracranial  serous 
effusion  and  marked  rigidity  of  the  muscles  of  the  nucha,  with  retrac- 
tion of  the  head. 

Paralysis  is  another  occasional  symj)tom,  but  complete  paralysis  of 
any  nniscle  or  group  of  nniscles  is  less  freijiicnt  than  one  would  suj)pose 
from  the  nature  of  the  malady.  It  may  occur  early,  but  is  souu'times 
a  late  symjitom.  It  may  be  limited  to  one  or  two  of  the  limbs,  as  the 
Iv^gs,  or  an  arm  and  a  leg,  or  it  may  be  more  general.  In  a  case  occur- 
ring in  Roosevelt  Hospital,  and  published  in  the  New  York  Medical 
Ixrcnrd  for  October  10,  1878,  the  patient,  a  boy  of  ten  years,  was 
unable  to  move  his  legs  one  hour  after  the  commencement  of  the  disease. 

24 


370  CEREBRO-SPINAL    FEVER. 

This  sudden  development  of  paraplegia  in  the  commencement  of  cerebro- 
spinal fever  resembled  that  of  infantile  paralysis,  and  was  probably  due 
to  the  same  cause,  to  wit,  active  intlaminatory  congestion  of  the  an- 
terior cornua  of  the  spinal  column.  The  sudden  and  complete  loss 
of  speech  Avhich  occurs  in  certain  cases,  when  consciousness  is  retained 
and  the  vocal  organs  are  in  their  normal  state,  seems  to  be  due  to  the 
fact  that  the  portion  of  the  brain  which  controls  the  function  of  speech 
is  acutely  congested,  or  is  the  seat  of  effusion.  Thus  in  June,  1882,  a 
girl  of  three  years,  whom  I  attended,  lost  her  speech  on  the  second  day 
of  cerebro-spinal  fever,  and  she  was  unable  to  articulate  even  the  sim- 
plest word  for  two  and  a  lialf  months.  Finally  she  began  to  utter  slowly 
and  with  difficulty  the  easiest  monosyllables,  and  now,  after  a  lapse  of 
more  than  a  year,  her  speech  is  slow  and  lisping,  while  her  hands  are 
tremulous  and  unsteady.  She  is  easily  fatigued  and  cries  often  from 
over-sensitiveness.  During  the  long  period  of  speechlessness  she  daily 
made  efforts  to  talk,  but  without  uttering  a  sound.  Strabismus,  to 
which  Ave  Avill  allude  hereafter  in  treating  of  the  eye,  is  a  connnon  symp- 
tom, either  transient  or  protracted,  due  to  paralysis  of  certain  of  the 
motor  muscles  of  the  eye. 

Paralysis  of  more  or  fewer  muscles  has  been  noticed  and  recorded  by 
many  observers  in  this  country  and  in  Europe.  Dr.  LaAV  observed  a 
patient  in  the  epidemic  of  18(35,  in  Dublin,  Avho  could  move  neither 
arms  nor  legs,  and  Wunderlich  saw  one  avIio  had  paralysis  of  both  loAver 
extremities  and  a  considerable  part  of  the  trunk.  As  this  symptom  is 
due  to  the  inflammatory  process  in  the  cerebro-spinal  axis,  it  usually 
disappears  in  a  few  weeks  as  the  inflammation  abates  and  absorption  of 
the  inflammatory  products  occurs,  but  it  may  be  more  protracted.  In 
Wunderliehs  case  there  was  only  partial  recovery  from  the  paralysis 
after  the  lapse  of  five  months. 

Clonic  convulsions  have  already  been  alluded  to  among  the  early 
symptoms  of  the  attack.  They  indicate  a  grave  form  of  the  disease, 
and  are  not  infrequent  in  young  children,  in  whom  they  appear  to  occur 
in  place  of  tlie  chill  which  is  common  in  those  of  a  more  advanced  age. 
Tiie  eclamptic  attack  may  be  short  and  not  repeated,  or  it  may  be  pro- 
tracted, or  return  awain  and  aji-ain  when  the  medicines  which  control  it 
are  suspended.  Under  such  circumstances  it  is  apt  to  end  in  profound 
coma,  and  is,  of  course,  a  symptom  of  great  gravity.  Thus  an  infant 
of  seven  months  had  unilateral  eclamptic  attacks  daily  during  the  first 
Aveek  of  the  attack.  The  mother  informed  me  that  the  convulsions 
seldom  lasted  longer  than  tin'ee  minutes,  and  that  the  intervals  between 
them  Avere  short.  The  child  recovered  with  loss  of  sight  from  the 
cerebro-spinal  fever,  but  still  after  the  lapse  of  a  year,  Avhcn  I  exam- 
ine<i  him,  had  symptoms  Avhich  Avere  apparently  due  to  hydrocephalus. 
Another  infant  of  eleven  months  had  clonic  convulsions  nearly  con- 
stantly during  the  first  twenty-four  hours,  but  Avith  occasional  brief 
intermissions.  On  the  folloAving  day  he  was  in  profound  coma,  and 
apparently  dying,  Avith  a  temperature  of  105°.  To  my  astonishment 
he  irraduallv  emer<]i;ed  from  the  state  of  unconsciousness,  and  after  a 
Aveek  Avas  able  to  sit  in  his  cradle  long  enough  to  take  drinks. 

Occasionally  eclampsia  does  not  occur  in  the  first  days,  but  in  the 


DIGESTIVE    SYSTEM.  371 

second  or  third  week,  when  it  is  usually  accompanied  by  an  increase  of 
other  symptoms,  due  to  a  recrudescence  of  the  disease.  A  female 
infant,  aged  eleven  months,  treated  by  me  in  1882,  had  been  sick  one 
week,  when,  during  an  increase  in  the  febrile  movement,  she  had  one 
eclamptic  seizure.  Her  recovery  though  slow  was  complete.  A  boy, 
aged  eleven  and  one-half  years,  whose  attack  began  with  a  chill,  violent 
headache,  and  a  febrile  movement,  and  whom  I  visited  frequently,  died 
on  the  fourth  day.  Clonic  convulsions  did  not  occur  in  his  case  until 
within  twenty-four  hours  of  his  death,  when  he  had  six  seizures,  Avhich 
ended  in  coma. 

Though  adult  patients  are  much  less  liable  to  eclampsia  than  children, 
they  are  not  entirely  exempt.  A  male  patient,  aged  twenty-eight  years, 
whom  I  saw  in  consultation,  had  a  single  clonic  convulsion  lasting  ten 
to  fifteen  minutes  on  the  third  day  of  his  illness.  In  five  Aveeks  he  had 
fully  recovered,  except  that  his  headache  returned  upon  any  excitement. 
Even  drinking  a  cup  of  beer  caused  it.  Clonic  convulsions  are,  how- 
ever, much  less  common  tlian  tonic  muscular  contraction  and  rigidity 
already  alluded  to.  This  occurs  to  a  greater  or  less  extent  in  nearly 
all  cases,  and  is  a  symptom  of  diagnostic  value,  the  rigidity  often  ex- 
tending to  the  muscles  of  the  extremities.  Thus  in  a  child,  aged  three 
years,  who  had  no  eclampsia,  the  tonic  contraction  of  the  muscles  of  the 
extremities  did  not  relax  till  after  the  twelfth  day. 

Choreic  or  clioreiform  movements  are  occasionally  observed.  I  do 
not  allude  to  the  tremulousness  which  sometimes  occurs  from  weakness, 
or  as  a  premonition  of  eclampsia,  but  a  movement  which  has  the  char- 
acter of  true  chorea.  An  infant,  aged  ten  months,  began  to  have  choreic 
movements  during  the  acute  stage  of  the  disease,  most  marked  in  the 
upper  extremities,  and  ceasing  in  sleep.  They  continued  during  the 
remainder  of  the  life  of  the  child,  death  occurrinnr  ten  months  subse- 
quently  fi-om  diphtheria.  Rarely  a  choreiform  movement  of  the  eyes  is 
also  observed,  a  lateral  movement  from  right  to  left,  and  left  to  right. 
I  have  seen  from  recollection  two  such  cases. 

Drowsiness,  already  alluded  to,  is  a  common  symptom,  and  it  exists 
in  all  grades,  from  slight  stupor  to  profound  coma.  In  some  patients 
it  is  |)resent  from  the  first  hour,  while  in  others  it  occurs  after  a  period 
of  restlessness  or  delirium,  or  it  alternates  with  it.  Stupor  more  or  less 
profound  is  common  after  the  attack  of  eclampsia  or  the  dull.  That  it 
is  a  frequent  symptom  in  severe  cases  receives  ready  explanation  from 
the  state  of  the  brain  and  its  meninges,  for  the  exudation  which  occura 
upon  the  surface  of  the  brain  and  the  serous  effusion  within  the  ven- 
tricles are  suflicient  to  cause  it,  by  compressing  the  cerebral  substance. 
It  IS  surprising  in  some  cases  how  profound  the  stupor  may  be,  a  state 
indeed  of  coma,  and  yet  the  patient  gradually  emerges  from  it  and 
recovers.  In  the  epidemic  of  1872,  in  New  York  City,  when  the 
malady  wns  new  with  us,  many  physicians  predicted  certain  death,  and 
employed  remedies  without  expectation  of  any  benefit,  on  account  of  the 
apj)arently  liopeless  state  of  patients,  who  seeuKMl  to  be  in  profound 
coma,  and  yet  not  a  few  of  them  gradually  ami  fully  recovered 

Di(Jf:stive  System. — Vomiting,  whieh  is  the  most  prominent  symp- 
tom  referable  to  the  digestive   svstem,   has  already  been  alluded  to. 


372  CEREBRO-Sl'INAL    FEVER. 

Occurring  early  in  the  disease,  it  may  cease  in  a  few  hours,  or  not  til) 
after  several  days,  and  often  it  returns  during  the  periods  of  recrudes- 
cence which  are  couinion  in  the  progress  of  the  fever.  It  occurs  with 
little  cftbrt,  and  without  previous  nausea,  or  with  little  nausea,  as  is 
usual  when  it  lias  a  cerebral  origin.  It  does  not  differ  as  a  symptom 
from  the  vomiting  which  is  so  common  in  other  forms  of  meningitis. 
The  substance  vomited  consists  of  the  ingesta  and  the  secretions,  as 
mucus  and  bile.  Having  a  similar  origin  is  a  sensation  of  faintness  or 
depression  referred  to  the  epigastrium. 

The  appetite  is  usually  impaired  or  lost  during  the  active  period  of 
the  attack,  and  it  is  not  fully  restored  till  convalescence  is  well  advanced. 
Occasionally  considerable  nutriment  is  taken,  and  with  apparent  relish, 
as  by  one  of  my  patients,  twenty-eight  years  of  age,  who  always  had 
some  appetite.  Ordinarily,  on  account  of  repeated  vomitings,  constant 
febrile  movement,  impaired  appetite  and  digestion,  patients  progressively 
lose  ilesh  and  strength,  so  that  in  protracted  cases  emaciation  is  always 
a  prominent  symptom,  and  is  often  extreme.  Great  emaciation  and  loss 
of  strength,  which  attend  many  cases  after  the  lapse  of  several  Aveeks, 
greatly  diminish  the  chances  of  a  favorable  termination.  Thirst,  already 
alluded  to,  and  constipation  are  common  in  this  as  in  other  forms  of 
meningitis,  but  retraction  of  the  abdomen  is  not  a  notable  sym])t<)m, 
except  in  protracted  and  greatly  Avasted  cases.  The  diarrhea  which  is 
occasionally  present  in  cerebro-spinal  fever  in  the  summer  months  must 
be  regarded  as  a  distinct  disease  and  a  complication.  The  tongue,  buccal 
and  faucial  surfaces  present  nothing  unusual  in  their  appearance.  It  is 
seldom  that  the  sordes  and  dry  and  brownish  fur  occur,  which  are  so 
common  in  typhus  and  typhoi<l  fevers,  even  in  the  most  protracted  and 
emaciated  cases.     The  tongue  is  usually  moist  and  but  slightly  furred. 

I  have  seen  in  consultation  two  patients  that  perished  early  with  in- 
ability to  swallow  as  the  prominent  symptom,  attended  in  both  by  an 
abundant  secretion  upon  the  faucial  surflice,  without  any  redness,  savcII- 
ing,  or  other  evidence  of  inflammation.  The  early  death  of  these  young 
children,  Avhose  ages  were  ten  months  and  two  years,  rendered  the  diag- 
nosis less  certain  than  in  most  other  patients,  but  the  attending  physi- 
cians as  well  as  myself  diagnosticated  cerebro-spinal  fever  with  suddenly 
developed  paralysis  of  the  muscles  of  deglutition,  so  that  no  nutriment 
could  be  taken.  If  our  understanding  of  these  interesting  cases  is  cor- 
i-ect,  the  paralysis  Avas  caused  by  lesion  of  that  portion  of  the  medulla 
oblongata  which  controls  the  function  of  deglutition,  or  else  from  injury 
of  the  intracranial  portions  of  the  nerves  Avliich  supply  the  muscles  con- 
cerned in  this  act.      The  following  Avcre  the  cases  alluded  to : 

O ,  male,  tAvo  years  of  age,  became  feverish  and  dull,  but  Avithout 

vomiting,  on  October  22,  1882;  axillary  temperature,  102\  On  the  fol- 
loAving  day  inability  to  swallow  occurred,  and  the  muscles  of  degluti- 
tion appeared  totally  inactiA^e.  Death  occurred  on  the  third  day,  suddenly, 
and  apparently  easily,  as  if  from  arrested  function  of  important  nerves, 
especially  the  pneumogastric.  The  abundant  secretion  of  thin  mucus  or 
transudation  of  serum  coA'ering  the  faucial  surftice,  and  reaccumulating  as 
soon  as  removed,  Avithout  any  notable  change  in  the  appearance  of  the 
fauces,  Avas  remarkable.     The  physician  in  attendance,  Avho  for  more  than 


TEMPERATURE.  37H 

thirtv  years  had  had  a  large  city  practice,  had  seen  no  similar  case,  nor 
had  I  at  the  time. 

Soon  afterward  the  second  case  occurred.  An  infant  of  ten  months, 
without  cougli  or  embarrassment  of  respiration,  or  faucial  redness  or 
swelling,  lost  the  power  of  deglutition  soon  after  the  commencement  of  the 
supposed  cerebro-si)inul  fever,  so  that  in  the  attempts  to  swallow  the  drinks 
entered  the  larynx,  and  the  secretion  or  exudation  was  al)undant  as  in  the 
other  case.  Death  occurred  in  forty-eight  hours.  The  rectal  tempera- 
ture was  only  101°. 

In  another  case,  ultimately  fatal,  and  in  which  the  diagnosis  of 
cerebro-spinal  fever  w'as  certain,  a  robust  girl,  aged  twelve,  suddenly 
lost  the  power  of  deglutition  at  one  time  during  her  sickness,  although 
she  was  entirely  conscious  and  repeatedly  endeavored  to  swallow.  The 
ability  to  swallow  returned  in  a  few  days. 

Pul.se. — This  is  usually  accelerated,  and  the  more  severe  and  dan- 
gerous the  attack,  the  more  rapid  the  heart's  action,  except  occasionally 
in  the  comatose  state,  when  probably,  in  consequence  of  compression  of 
the  brain  from  an  abundant  exudation,  the  pulse  may  be  subnormal. 
Thus,  in  one  of  my  patients,  an  adult,  the  pulse  fell  to  40  per  minute, 
and  in  two  others  between  GO  and  70  per  minute.  With  trie  exception 
of  these  three  patients,  the  pulse  in  all  cases  which  I  have  observed,  so 
far  as  I  recollect,  has  varied  from  the  normal  number  of  beats  per 
minute  to  such  frequency  that  it  was  difficult  to  count  it.  As  death 
draws  near  the  pulse  ordinarily  becomes  more  frequent  and  feeble. 
Intermissions  in  the  pulse  do  not  seem  to  be  as  common  as  in  other 
forms  of  meningitis,  but  marked  variations  in  its  frequency  during  dif- 
ferent hours  of  the  day,  and  on  consecutive  days,  is  a  conspicuous 
symptom.  Thus,  in  a  case  whicli  was  fatal  in  the  fifth  week,  consecu- 
tive enumerations  of  the  pulse,  in  the  acute  stage,  were  as  follows,  128, 
120,  88,  130,  84,  112. 

Ti:mfeiiature. — Some  of  the  older  writers,  before  the  days  of  clin- 
ical thermometry,  stated  that  the  temperature  is  not  increased.  North 
remtirked  as  follows  :  "  Cases  occur,  it  is  true,  in  which  tlio  temperature 
is  increased  a1>ove  the  natural  standard,  but  these  are  rare,"  and  Foot 
and  Gallop  make  similar  statements.  Some  recent  writers  have  held 
the  same  opinion.  Thus  Lidell  wrote  as  follows  in  a  treatise  bearing 
the  date  of  1873:  ".  .  .  .  Febrile  symptoms  do  not  necessarily 
belong  to  epidemic  cerebro-spinal  meningitis,  as  a  substantive  disease, 
for  it  may,  and  not  urifrecpiently  does  occur,  Avithout  exhibiting  any 
such  symptoms."  We  would  naturally  expect  that  meningitis,  accom- 
panied as  it  is  by  active  congestion  of  the  brain  and  spinal  cord,  would 
])roduce  more  or  less  fever,  and  in  eighty-six  cases  which  I  have  exam- 
ined by  the  thermometer,  I  have  found  elevation  of  temperature  in 
every  case  during  the  acute  stage,  except  in  the  beginning  of  the  attack 
in  two  instances.  In  a  young  man,  agc-d  twenty-eight  years,  who  had 
severe  headache  and  seemed  seriously  sick,  the  tliermometer  under  the 
tongue  showed  no  rise  of  temperature  on  the  first  and  second  diiys,  but 
on  the  third  day  it  was  at  100°,  and  it  remained  elevatetl  till  ]\\<  (h-ath, 
on  the  thirteenth  day.  The  second  case  was  that  of  a  young  woman 
whom  I  saw  in  consultation,  and  who  at   the  time  of  my  visit    had 


374  CEREBRO-SPINAL    FEVER. 

decided  febrile  movement,  but  who,  like  the  young  man,  had  no  rise  of 
temperature  on  tlie  first  and  second  days,  according  to  the  careful  obser- 
vations of  the  attending  physician.  In  the  eighty-six  cases  which  I  have 
examined,  the  heat  of  the  surface  occasionally  did  not  seem  above  normal 
to  the  touch,  and  now  and  then  the  thermometer,  applied  in  the  axilla 
or  groin,  did  not  indicate  fever,  but  the  rectal  temperature  was  always 
elevated  above  that  of  health  after  the  disease  was  fully  established. 
The  temperature  fluctuated  from  day  to  day,  and  in  different  hours  of 
the  same  day,  but  there  was  no  exception  after  the  second  day  to  the 
rule,  that  it  is  supra-normal  during  the  active  stage  of  the  malady. 
Sometimes  the  elevation  of  temperature  was  slight,  as  in  a  female 
patient,  forty-seven  j^ears  of  age,  whom  I  was  allowed  to  examine  with 
the  family  physician.  The  thermometer  showed  no  elevation  of  tem- 
perature when  it  was  placed  in  the  mouth  and  axilla,  but  on  introducing 
it  into  the  rectum  it  rose  to  *J0J°. 

The  highest  temperature  which  I  have  thus  flir  observed,  was  107f  °, 
in  a  child  aged  two  years.  This  was  in  the  commencement  of  the  attack. 
Subsequently  it  fell  a  little,  but  rose  again  on  the  third  day  to  107°, 
when  she  died.  In  two  other  cases  the  temperature  was  106°  on  the 
first  day,  and  it  did  not  afterward  reach  so  high  an  elevation.  One  of 
these  died  on  the  ninth  day,  and  the  other  in  the  ninth  Aveek.  The 
next  highest  temperature  was  105|°,  also  on  the  first  day,  in  an  infant 
aged  eight  months,  who  died  on  the  ninth  day.  The  first  and  last  of 
these  cases  occurred  in  an  old  wooden  tenement-house  in  the  suburbs 
of  the  city,  and  upon  an  elevated  outcropping  of  rock.  The  highest 
temperature  in  any  case  in  New  York  City  which  has  come  to  my 
notice,  was  observed  in  a  male  patient  aged  twenty-eight  years,  wdio 
had  active  delirium  and  died  on  the  fifth  day  in  Roosevelt  Hospital. 
The  temperature  on  the  last  day,  taken  four  times,  was  as  follows: 
102|°,  10(3|°,  and  when  the  pulse  had  become  imperceptible,  109°  and 
107|°  Wunderlich  has  recorded  a  temperature  of  11U°  in  one  or  two 
cases,  but  so  great  an  elevation  must  be  very  rare,  and  is,  of  course, 
prognostic  of  an  unfavorable  ending. 

The  external  temperature  undergoes  still  greater  fluctuations  than 
the  internal,  rising  above  and  falling  below  the  normal  standard  several 
times  in  the  course  of  the  same  day.  Similar  fluctuations  occur  in  other 
forms  of  meningitis,  but  they  are,  according  to  my  experience,  less  pro- 
nounced than  in  cerebro-spinal  fever,  esj)ecially  as  I  observed  them  in  the 
ei)i<lemic  of  1872.  Perhaps  since  that  epidemic  they  have  been  less 
marked  in  the  cases  occurring  in  this  city.  The  more  grave  the  attack 
in  those  not  comatose,  the  greater  these  variations.  The  followmg  is  a 
common  example,  in  a  patient  aged  two  years.  Without  any  notable 
change  in  other  sym])toms,  tlie  internal  temperature  varied  from  101° 
to  1044°  as  the  extremes,  wJiile  that  of  the  fingers  and  hands  at  the 
first  examination  was  U0i°,  at  the  second  00°,  at  the  third  103°,  and 
at  the  fourth  83°.  Hence  at  the  third  examination  the  temperature  of 
the  extremities  had  risen  13°,  so  as  nearly  to  equal  that  of  the  blood,  and 
at  the  fourth  examination  it  had  fallen  20°.  The  patient  recovered. 
These  great  and  sudden  variations  in  the  pulse,  and  the  internal  and 


RESPIRATORY    SYSTEM.  375 

external  temperature,  have  considerable  diagnostic  value  in  obscure  and 
doubtful  cases. 

Respiratory  System. — This  system  is  not  notably  involved  in  ordi- 
nary cases.  Intermittent,  sighing,  or  irregular  respiration  appears  to 
be  less  frequent  than  in  ordinary  meningitis,  but  it  does  occur.  In 
most  patients  the  respiration  is  quiet,  but  somewhat  accelerated,  and 
Avithout  any  marked  disturbance  in  its  rhythm.  In  thirty-one  observa- 
tions in  children  "vvho  had  no  complication,  I  found  the  average  respira- 
tions 42  per  minute,  while  the  average  pulse  was  137.  Therefore  the 
respiration,  as  compared  Avith  the  pulse,  was  proportionately  more  fre- 
quent than  in  health,  due  perhaps  to  the  fact  that  certain  muscles  con- 
cerned in  respiration,  as-  the  abdominal,  are  embarrassed  in  their 
movements  by  tonic  contraction. 

Various  observers,  in  different  epidemics,  have  recorded  an  unusual 
prevalence  of  croupous  pneumonia  occurring  simultaneously  with  the 
cerebro-spinal  fever.  Bascome,  in  his  history  of  epidemics,  stated  that 
"  epidemic  encephalitis  and  malignant  pneumbiiias  prevailed  in  Ger- 
many in  the  sixteenth  century"  (Webber).  Webber,  in  his  prize  essay, 
describes  a  variety  of  cerebro-spinal  fever,  which  he  designates  pneu- 
monic, in  which  the  cerebro-spinal  axis  is  involved  but  slightly  or  not 
at  all,  and  the  brunt  of  tlie  disease  falls  upon  the  respiratory  organs. 
According  to  him,  in  certain  epidemics  the  pneumonic  form  has  been 
common  and  in  others  infrequent. 

In  New  York  City,  during  the  epidemic  of  cerebro-spinal  fever  in 
1*^72,  pneumonia  was  also  unusually  prevalent,  affecting  many  old  as 
well  as  young  people.  According  to  the  statistics  of  the  New  York 
Board  of  Health,  seventeen  hundred  and  seven  deaths  from  diseases  of 
the  resi)iratory  organs,  exclusive  of  phthisis,  occurred  during  tlie  four 
months  from  February  1  to  June  1,  1872,  Avhen  the  epidemic  of  cere- 
bro-spinal fever  was  at  its  lieight,  and  only  thirteen  hundred  and  forty- 
six  deaths  occurred  from  the  same  diseases  during  the  remaining  eight 
months  of  the  year;  and  as  phthisis  is  excluded,  the  only  other  disease 
of  the  respiratory  system  besides  pneumonia  which  causes  a  largo  mor- 
tality is  membranous  croup,  which  did  not  seem  to  be  unusually  prevar 
lent  during  these  four  months.  It  is  therefore  probable,  though  not 
distinctly  stated  in  the  annual  r  >port  of  the  Health  Board  for  that  year, 
that  the  great  mortality  from  diseases  of  the  respiratory  organs,  during 
that  [)art  of  1872  when  cerebro-spinal  fever  Avas  epidemic,  was  chiefly 
from  pneumonia,  and,  according  to  my  observations,  many  cases  of 
pneumonia  during  that  period  jtresented  symptoms  of  greati'r  gravity 
than  usually  accompany  this  form  of  inflammation.  The  patients  were 
greatly  prostrated  from  the  first,  and  in  some  of  them  febrile  movement, 
muscular  ))ains,  restlessness,  or  delirium  preceded  for  liours  or  even  days 
the  pneumonic  symptoms,  affoi'ding  evidence  that  the  lung  disease 
occurn'(l  inider  certain  unusual  circumstances  or  conditions  Avhich  modi- 
fied its  character.  It  is  not  improbable  therefore  that  Webber's  view 
is  correct,  that  there  are  occasional  cases  of  cerebro-spinal  meningitis 
with  ))neumonia  as  one  of  its  local  manifestati(ms.  In  the  New  York 
epidemic  of  1872  a  prominent  citizen  had  a  s;n'ere  attack  of  what  was 
supposed  to  be  cerebro-spinal  fever,  one  of  his  medical  advisers  being 


376  CEREBRO-SPINAL    FEVER. 

known  throuo-hout  the  country  for  liis  ability  in  diagnosis.  On  the 
sixth  (lay  the  cerebro-spinal  symptoms  considerably  abated,  pneumonia 
appeared,  and  subsequently  the  prominent  symptoms  were  referable  to 
the  lungs.     He  slowly  recovered. 

Cutaneous  Surface. — The  features  may  bo  ])allid,  of  normal  ap- 
pearance or  flushed  in  the  first  days  of  the  disease,  but  in  advanced 
cases  they  arc  ])allid,  as  is  the  skin  generally.  A  circumscribed  patch 
of  deep  congestion  often  appears,  as  in  sporadic  meningitis,  ujion  some 
part  of  them,  as  the  forehead,  cheek,  or  an  ear,  and  after  a  short  time 
disappears.  The  hypergemic  streak,  the  tache  cerehrale  of  Trousseau, 
produced  by  drawing  the  finger  firmly  across  the  surface,  also  appears 
as  in  other  forms  of  meningitis,  if  the  temperature  of  the  surfiice  be  not 
too  much  reduced. 

The  following  are  the  abnormal  appearances  of  the  skin  most  fre- 
quently observed :  1.  Papilliform  elevations,  the  so-called  goose-skin, 
due  to  contractions  of  the  muscular  fibres  of  the  corium.  This  is  not 
uncommon  in  the  first  weeks.  2.  A  dusky  mottling,  also  common  in 
the  first  and  second  Aveeks  in  grave  cases,  and  most  marked  when  the 
temperature  is  reduced.  3.  Numerous  minute  red  points  over  a  large 
part  of  the  surface,  bluish  spots  a  few  lines  in  diameter,  due  to  extrava- 
sation of  blood  under  the  cuticle,  resembling  bruises  in  appearance,  and 
large  patches  of  the  same  color,  an  inch  or  more  in  diameter,  less  com- 
mon than  the  others,  of  irregular  shape  as  well  as  size,  and  usually  not 
more  than  two  or  three  upon  a  patient.  These  last  resemble  bruises,  and 
they  may  sometimes  be  such,  received  during  the  times  of  restlessness  ; 
but  ordinarily  extravasations  of  tliis  kind  result  entirely  from  the  altered 
state  of  the  blood.  In  New  York,  in  the  epidemic  of  1872,  they  were 
common,  but  since  this  epidemic,  in  the  thirty-six  cases  which  I  liave 
observed,  I  have  rarely  seen  either  the  reddish  points  or  the  extravasa- 
tions of  blood.  They  were  probably  common  in  the  epidemics  in  the 
first  part  of  this  century  in  this  country,  since  the  disease  was  designated 
by  the  name  spotted  fever  by  the  American  physicians  who  wrote  upon 
it  at  that  time.  That  they  are  unusual  in  the  European  epidemics  at 
the  present  time,  we  infer  from  the  fact  that  Von  Ziemssen  expresses 
surprise  that  the  disease  should  ever  have  been  designated  in  America 
by  such  a  title.  4.  Herj^es.  This  is  common.  It  sometimes  occurs 
as  early  as  the  second  or  third  day,  but  in  other  instances  not  till  toward 
the  close  of  the  first  week  or  in  the  second.  The  number  of  herpetic 
eruptions  varies  from  six  or  eight  to  clusters  as  large  or  larger  than  the 
hand.  This  cutaneous  disease  evidently  has  a  nervous  origin,  the  vesi- 
cles occurring  in  most  instances  on  those  j)arts  of  the  surface  which  are 
supplied  by  branches  of  the  fifth  pair  of  nerves.  Its  most  common 
seat  is  upon  the  lips,  but  occasionally  it  appears  upon  the  cheek,  ui)on 
and  around  the  ears,  and  upon  the  scalp.  Erythema  and  roseola  fugi- 
tive skin  eruptions  occasionally  ajjpear,  and  in  one  instance  in  my  prac- 
tice erysipelas  occurred.  During  the  first  days  the  skin  is  frequently 
dry ;  afterward  perspirations  are  not  unusual,  and  fr-ee  perspirations 
sometimes  occur,  esjjecially  about  the  head,  face,  and  neck. 

Urinary  Organs. — In  other  fi)rms  of  meningitis  it  is  well  known 
that  the  quantity  of  urine  excreted  is  usually  diminished,  but  in  this 


THESPECIALSEXSES.  oi  t 

disease  it  is  normal,  and  it  may  be  more  than  normal.  Polyuria  has 
been  noticed  in  different  cases  by  various  observers.  Mosler  observed 
a  boy  aged  seven  years,  who  had  an  excessive  secretion  of  ui-'»e, 
which  dated  back  to  an  attack  of  cerebro-spinal  fever  in  his  third  yeai. 
The  polyuria  is  probably  due  to  injury  of  the  nervous  centre,  since  it 
is  established  by  physiological  experiment  that  irritation  of  the  central 
end  of  tlie  vagus,  of  certain  parts  of  the  cerebellum,  and  of  the  walls  of 
the  fourth  ventricle,  sometimes  produces  this  effect.  The  urine  occa- 
sionally contains  a  moderate  amount  of  albumen,  and  in  exceptional 
instances  cylimlriral  casts  and  blood-corpuscles. 

Arthritic  inffammation,  apparently  of  a  rheumatic  character,  has  been 
occasionally  observed.  I±  is  commonly  slight,  producing  merely  an 
oedematous  appearance  around  one  or  more  joints.  Thus  in  one  case 
which  came  under  my  notice,  and  which  was  subsequently  fatal,  tlie 
parents,  who  were  poor,  and  were  therefore  without  medical  advice  till 
the  case  Avas  somewhat  advanced,  had  already  diagnosticated  rheuma- 
tism on  account  of  the  puffiness  which  they  had  noticed  around  one  of 
the  wrists. 

The  Special  Senses. — Taste  and  smell  are  rarely  affected,  so  far 
as  is  known,  but  it  is  possible  that  they  are  sometimes  jierverted,  or 
even  temporarily  lost,  during  the  time  of  greatest  stupor.  In  one  case, 
which  I  saw,  the  sense  of  smell  Avas  entirely  lost  in  one  nostril,  and  I 
do  not  know  whether  it  was  ever  fully  restored. 

The  affc'ctions  of  the  eye  and  ear  are  important  and  of  frequent  occur- 
rence. Strabismus  is  common.  It  may  occur  at  any  period  of  the 
fever,  continuing  a  few  hours  or  several  days,  and  it  may  appear  and 
disappear  several  times  before  convalescence  is  established  ;  occasionally 
it  continues  several  weeks,  after  which  the  parallelism  of  the  eyes  is 
gradually  and  fully  restored.  In  other  instances  it  is  ])ermanent. 
Thus  in  a  boy  of  five  years,  whom  I  last  saw  three  months  after  conva- 
lescence, there  were  still  convergent  strabismus  of  the  right  eye  and 
double  vision ;  and  in  a  boy  of  three  years,  convergent  strabisnuis  of 
the  right  eye  remained  when  I  examined  him  twelve  months  after  the 
occurrence  of  the  fever. 

Changes  in  the  ])Uitils  are  among  the  first  and  most  noticeable  of  the 
initial  symptoms,  as  I  have  already  stated  in  describing  the  mode  of 
commencement.  These  are  dilatation,  less  frequently  contraction,  oscil- 
lation, inequality  of  size,  feeble  response  to  light,  etc.  Most  patients 
present  one  or  more  of  these  abnormalities  of  the  ])iij)ils,  and  thev  con- 
tinue during  the  first  and  second  weeks,  and  gradually  abate,  if  the 
course  of  the  disease  be  fiivorable.  Inflammatory  liyj)eritMnia  of  the 
conjunctiva  often  occurs.  It  begins  early,  and  now  and  theJi  the  con- 
junctivitis is  so  intense  that  considerable  tumefaction  of  the  lids  results, 
with  a  free  rnuco-purulent  secretion.  The  false  diai^nosis  has  indeed 
been  made  of  piindent  ophthalmia,  in  cases  in  whii-li  this  affectiim  of 
the  litis  was  early  and  severe.  But  such  intense  inllamnialion  is  <piite 
exceptional.  More  frequently  there  is  a  uniform  diOused  redness  ot 
the  conjunctiva,  not  so  dusky  as  in  typhus,  and  the  injected  vessels 
cannot  be  so  readily  distinguished  as  in  that  disease. 

In  certain  cases  almost  the  whole  eye  (all  indeed  of  the  important 


878  CEREBRO-SPINAL    FEVER. 

constituents)  becomes  inflamed ;  the  media  grow  cloudy,  the  iris  dis- 
colored, and  the  pupils  uneven  and  filled  up  with  fibrinous  exudation. 
The  deep  structures  of  the  eye  cannot,  therefore,  be  readily  explored 
by  the  ophthalmoscope,  but  they  are  observed  to  be  adherent  to  each 
other,  and  covered  by  inflammatory  exudation.  They  present  a  dusky 
red,  or  even  a  dark  color,  Avhen  the  inflammation  is  recent.  Exception- 
ally the  cornea  ulcerates  and  the  eye  bursts,  "with  the  loss  of  more  or 
less  of  the  liquids,  and  shrinking  of  the  eye.  "  But  ordinarily  no 
ulceration  occurs,  and,  as  the  patient  convalesces,  the  oedema  of  the  lids, 
hypergemia  of  the  conjunctiva,  the  cloudiness  of  the  cornea,  and  of  the 
humors,  gradually  abate,  and  the  exudation  in  the  pupils  is  absorbed. 
The  iris  bulges  forward,  and  the  deep  tissues  of  the  eye,  viewed  through 
the  vitreous  humor,  Avhieh  before  had  a  dusky  red  color  from  hyper- 
gemia, now  present  a  dull  white  color.  The  lens  itself,  at  first  transpa- 
rent, after  awhile  becomes  cataractous.  Sight  is  lost  totally  and  forever. 
This  form  of  ophthalmia  is  sometimes  rapidly  developed,  as  in  the  fol- 
lowing example : 

On  July  T),  1873,  I  was  called  to  a  boy,  five  years  of  age,  who  had 
reached  the  tenth  day  of  cerebro-spinal  fever  without  apparently  any 
affection  of  the  eyes,  as  both  presented  the  normal  a])})earance.  On 
the  following  day  the  left  eye  was  red  and  swollen  from  the  inflamma- 
tion and  chemosis,  so  that  the  lids  could  not  be  closed,  and  the  media 
were  cloudy.     Death  occurred  on  the  same  day. 

If  the  patient  live  the  volume  of  the  eye  diminishes,  as  the  inflamma- 
tion abates,  to  less  than  the  normal  size,  even  Avhen  there  has  been  no 
rupture,  and  escape  of  the  fluids,  and  divergent  strabismus  is  apt  to 
occur.  Professor  Knapp,  whose  description  of  the  eye  I  have  for  the 
most  part  followed,  says :  "  The  nature  of  the  eye  affection  is  a  puru- 
lent choroiditis,  probably  metastatic."  Fortunately  so  general  and 
destructive  an  inflammation  of  the  eye  as  has  been  described  above  is 
comparatively  rare.  On  the  other  hand,  conjunctivitis  of  greater  or 
less  severity,  and  hypergemia  of  the  optic  disk,  consequent  upon  the 
brain  disease,  are  not  unusual,  but  they  subside,  leaving  the  function 
of  the  organ  unimpaired.  "  In  some  cases  incurable  blindness  is 
noticed  under  the  ophthalmoscopic  picture  of  optic  nerve  atrophy,  prob- 
ably the  seipience  of  choked  disk."     (Knapp.) 

Inflammation  of  the  middle  ear,  of  a  mild  grade,  and  subsiding  Avith- 
out  impairment  of  hearing,  is  common.  The  membrana  tymjjani,  during 
its  continuance,  presents  a  dull  yellowish,  and  in  places  a  reddish  hue. 
Occasionally  a  more  severe  otitis  media  occurs,  ending  in  suppuration, 
perforation  of  the  membrana  tyinpani,  and  otorrhoea,  which  ceases  after 
a  variable  time.  But  otitis  media  is  not  the  most  severe  of  the  affec- 
tions of  the  organs  of  hearing.  Certain  patients  lose  their  hearing 
entirely  and  never  regain  it,  and  that,  too,  with  little  otalgia,,  otorrhoea. 
or  other  local  symptoms  by  Avhich  so  grave  a  result  can  be  prognosti- 
cated. This  loss  of  hearing  does  not  occur  at  the  same  period  of  the 
disease  in  all  cases.  Some  of  those  Avho  become  deaf  are  able  to  hear 
as  they  emerge  from  the  stupor  of  the  disease,  but  lose  this  function 
durin;'  convalescence,  while  the  majority  are  observed  to  be  deaf  as 
soon  as  the  stupor  abates  and  full  consciousness  returns. 


THE    SPECIAL    SENSES.  879 

Two  important  facts  have  been  observed  in  reference  to  the  loss  of 
hearing  in  these  patients — to  Avit,  it  is  bikiteral  and  complete.  When 
first  observed  it  is,  in  some,  as  stated  above,  complete,  but  in  others 
partial,  and  Avhen  partial  it  gradually  increases  till  after  some  days  or 
weeks,  when  it  becomes  complete.  I  have  the  records  of  ten  cases  of 
this  loss  of  heiring,  most  of  them  occurring  in  my  own  practice  in  the 
epidemic  of  1872,  but  a  ft'w  of  them  detailed  to  me  by  the  physicians 
who  observed  them  in  the  same  epidemic.  According  to  these  statis- 
tics about  one  in  every  ten  patients  became  deaf,  but  in  the  milder 
form  of  cerebro-spinal  meningitis  which  has  prevailed  since  1872,  the 
proportionate  number  thus  affected  has  been  less  among  my  patients, 
and  the  same  may  be  said  in  reference  to  the  loss  of  sight.  One  of 
the  ten  cases  was  a  young  lady,  but  the  rest  were  children  under  the 
age  of  ten  years.  Professor  Knapj)  has  examined  thirty-one  cases. 
"In  all,"  says  he,  ''the  deafness  was  bilateral,  and  Avith  two  excep- 
tions of  faint  perceptions  of  sound,  complete.  Among  the  twenty-nine 
cases  of  total  deafness,  there  is  only  one  who^seemed  to  give  some  evi- 
dence of  hearing  afterward."  The  same  author  has  recently  informed  me 
that  further  experience  has  confirmed  his  previous  statement,  that  Avhile 
the  blindness  produced  by  cerebro-spinal  fever  is  in  the  majority  of  cases 
monolateral,  only  one  case  had  come  to  his  notice  in  Avhich  the  deafness 
was  on  one  side  only. 

One  theory  attributes  the  loss  of  hearing  to  inflammatory  lesions 
either  at  the  centre  of  audition,  Avithin  the  brain,  or  in  the  course  of 
the  auditory  nerves  before  they  enter  the  auditory  foramina.  Thus 
Stillcsivs:  "This  sym[)tom  aj)pears  to  depend  chiefly  upon  the  ])res- 
sure  of  the  plastic  exudation  in  which  the  nerves  are  embedded.  "  The 
other  theory  attributes  the  loss  of  hearing  to  inflammatory  disease  of 
the  ear,  and  especially  of  tiie  labyrinth.  Dr.  Sanderson,  who  is  an 
advocate  of  the  latter  theory,  remarks  as  follows:  "As  regards  the 
nature  of  the  affection,  there  apjjcars  to  be  good  reason  for  believing 
that,  like  the  blindness  observed  under  similar  circumstances,  and 
sometimes  in  the  same  cases,  it  is  (lei)en(lent  on  inflaunnatory  changes 
in  the  organ  of  hearincr  itself.     Dr.  Klebs  Avas  kind  enough  to  show  me, 

DO  O 

in  the  pathological  museum  of  the  Charite  at  Berlin,  a  preparation  of 
the  internal  ear  of  a  soldier  Avho  had  died  of  epidemic  meningitis,  coui- 
plicated  Avith  deafness,  in  Avhich  fihrinous  adhesions  existed  between  the 
bones  of  the  internal  ear  and  the  Avails  of  the  vestibule.  Dr.  Klebs 
stated  that  in  the  recent  state  the  mucous  lining  of  the  vestibule  Avas 
detached."  In  the  case  of  a  young  woman  Avho  was  deaf  from  tlic  com- 
mencement and  died  on  the  eighth  day,  "both  tympani  Averc  natural, 
l)ut  in  the  left  membrana  tympani  Avas  found  a  dense  Avhite  thickening  as 
large  as  a  ))in's-head.  On  the  sanu;  side  the  lining  membrane  of  the 
semicircular  canal  Avas  distinctly  thickened  and  loosed,  an<l  in  (he  ante- 
rior canal  there  Averc  semifluid  purulent  masses."  Professor  Kiia])|)  also 
states:  "  The  nature  of  the  ear  disease  is  in  all  probability  a  ))uruh'nt 
inflammation  of  the  labyrinth."  According  to  him.  no  disease  of  the 
middle  ear  could  cause  such  comf)lete  deafness ;  and  as  evidence  that 
the  deafness  is  not  due  to  central  disease.  Dr.  (inicning  ol>tained  hy 
electrization  the  normal  reaction  of  the  auditorv  nerve  Aviihin  the  era/- 


880  CEREBRO-SPINAL    FEVER. 

nium.  Moreover,  if  tlie  lesion  wliicli  destroys  hearing  be  within  the 
fvanium,  why  are  not  the  fiinetioiis  of  the  other  cranial  nerves  also 
abolished  ?  Again,  Drs.  Keller  and  Lucae  have  in  three  post-mortem 
examinations  found  evidences  of  disease  of  the  labyrinth. 

An  argument  in  support  of  the  former  of  these  theories  is  the  fact 
that  the  lesion  which  produces  the  deafness  is  not  ordinarily  attended 
by  any  marked  subjective  symptoms  referable  to  the  ear,  as  otalgia,  etc. 
Again,  the  fact  that  the  deafness  is  nearly  always  bilateral  and  simul- 
taneous in  the  two  ears,  comports  better  with  the  doctrine  of  a  central 
lesion,  than  with  that  which  locates  the  lesion  within  the  ear.  But  the 
true  theory  can  only  be  positively  established  by  dissections,  and,  as  Ave 
have  seen,  several  post-mortem  examinations  have  revealed  inflamma- 
tory disease  of  the  labyrinth  in  those  who  have  died  having  this  form  of 
deafness  ;  Avhile  in  no  case,  so  far  as  I  am  aware,  has  the  ear  been  found 
free  from  inflammatory  lesions.  Therefore  the  theory  which  ascribes 
the  deafness  to  disease  of  the  ear  is  much  better  established  than  the 
other,  and  must  be  accepted.  Moreover,  most  of  the  aurists  of  this 
city,  who  have  had  excellent  opportunities  to  examine  these  cases, 
believe  in  this  theory. 

Nature. — The  theory  that  cerebro-spinal  fever  is  a  local  disease, 
occurring  epidemically,  was  commonly  held  in  the  first  part  of  this  cen- 
tury, a  theory  which  is  now  discarded.  Job  Wilson,  in  1815,  con- 
sidered it  a  form  of  influenza,  and  he  could  see  no  utility  in  drawing  a 
distinction  between  spotted  fever  and  influenza.  We,  at  the  present 
time,  can  see  no  resemblance  between  the  two,  except  that  both  occur 
as  epidemics.  The  tlieory  that  cerebro-spinal  fever  is  a  peculiar  local 
disease  occurring  in  epidemics  is  more  plausible  than  that  it  is  a  form 
of  influenza.  Even  Niemeyer  says  that  it  presents  no  symptoms  except 
such  as  are  referable  to  the  local  affection.  But  the  evidence  is  strong 
that  cerebro-spinal  fever  is  a  constitutional  malady,  with  the  meningitis 
as  a  local  manifestation,  just  like  measles  with  its  bronchitis,  or  scarlet 
fever  with  its  pharyngitis.  The  abrupt  and  severe  commencement, 
unlike  that  of  those  forms  of  meningitis  which  are  known  to  be  strictly 
local,  and  the  early  blood  change,  as  shown  in  certain  cases  by  the 
appearance  of  the  skin  and  extravasations  under  it,  indicate  a  general 
disease.  Constitutional  diseases  having  prominent  local  symptoms  and 
lesions  are  usually  regarded  at  first  as  local.  It  is  only  as  time  goes 
on,  and  they  are  more  thoroughly  studied  and  understood,  and  clinical 
observations  multiply,  that  their  constitutional  nature  is  recognized,  as 
for  example  at  this  late  day  the  profession  are  beginning  to  recognize 
the  constitutional  nature  of  croupous  pneumonitis. 

The  theory  that  cerebro-spinal  fever  is  a  form  of  typhus  once  had 
advocates,  but  it  is  now  so  generally  discarded,  as  untenal)le  and  absurd, 
tliat  it  would  be  a  waste  of  time  to  consider  the  ficts  which  diflercntiate 
the  two  maladies.  Cerebro-spinal  fever  should,  therefore,  be  considered 
as  distinct  from  all  other  diseases,  a  malady  Hui  rjeneris^  and  in  noso- 
logical writings  it  should  be  classified  with  those  constitutional  maladies 
Avhich  have  specific  causes. 

Although  this  disease  ordinarily  occurs  in  an  epidemic  form,  in  local- 
ities widely  separated  from  each  other,  and  after  continuing  a  few  Avcekii 


NATURE.  381 

or  months,  totally  disappears,  perhaps  never  to  return,  or  not  till  after 
the  lapse  of  years,  nevertheless  in  certain  localities  it  becomes  estab- 
lished, so  that  it  is  proper  to  describe  it  as  an  endemic,  a  fact  to  Avhich 
we  have  already  alluded  as  regards  New  York  City.  I  do  not  know 
that  it  is  endemic  in  any  village  or  rural  locality  in  this  country,  but  it 
appears  to  be  permanently  established  in  certain  of  the  large  cities. 
The  large  cities,  with  their  promiscuous  population,  foreigners  and 
natives,  their  crowded  tenement-houses,  and  many  sources  of  insalubrity, 
furnish  in  an  eininent  degree  the  conditions  which  are  favoraljle  for  the 
development  and  perpetuation  of  the  specific  principle.  Those  diseases 
which  in  the  present  state  of  our  knoAvledge  we  have  reason  to  believe 
are  caused  by  microorganisms,  we  would  expect  to  prevail  most  Avhere 
domiciles  arc  crowded  and  filthy,  and  systems  are  enervated  by  impure 
air,  hardships,  and  privation.  Hence  in  New  York  City,  in  the  quar- 
ters of  the  poor,  there  is  a  constant  succession  of  the  infectious  diseases 
of  childhood.  Often  two  or  more  of  them  occur  simultaneously^  and  it 
is  difficult  to  eradicate  them  or  limit  their  ex-tension  when  once  they 
have  obtained  a  foothold.  The  fact  that  a  large  city,  with  its  tenement- 
house  population,  affords  in  an  eminent  degree  the  conditions  in  which 
the  infectious  diseases  are  developed  and  propagated,  when  once  their 
specific  principles  have  been  introduced,  is  one  of  the  chief  causes  of  the 
large  percentage  of  deaths  among  the  city  children.  In  New  Y'ork  what 
has  been  gained  in  saving  life  by  the  suppression  of  smallpox  has  been 
more  than  counterbalanced  by  the  mortality  produced  by  di[)htlieria  and 
cerebro-spinal  fever,  both  now  to  all  appearance  permanently  established 
in  our  midst.  The  following  table  gives  the  number  of  deaths  annually 
from  cerebro-spinal  fever  in  this  city  since  the  close  of  1871 : 

Xumher 
of  deaths. 

187-2 78'J 

1873 200 

1874 l.-,8 

1875 140 

187(3 V27 

1877 IIG 

1878 97 

1879 108 

1880 170 

1881 401 

1882 208 

It  is  seen  that  the  greatest  mortality  was  in  the  first  year  after  the 
introduction  of  the  disease  into  the  city,  after  Avhich  the  number  of 
deaths  gradually  diuiiuished,  year  by  year,  (ill  IHTS,  when  the  lowest 
mortality  Avas  reached.  Since  1ST8  the  nujrtality  gradually  increased 
till  ISSl,  in  whicli  year  the  inniiber  of  deaths  was  double  that  of  any 
other  year  excej)t  1872,  it  being  half  that  of  1N72.  The  weather  aud 
the  season  appear  to  exert  little  infiuence  on  the  prevalence  of  this  dis- 
ease now  that  it  is  cstablisheil  iu  the  city.  Fvnm  the  comuienc(;uuMit  of 
18S2  till  th(!  end  of  May  of  th(»  current  year  I  lind  that  it  Caused  (h-atlis 
in  every  week  except  one.  and  about  the  same*  nuuiber  in  cai-h  of  the 
seventeen  months  ouibraced  in  this  period. 

The  mortuary  reports  of  Philadelphia  likewise  show  that  cerebro- 


382  CEREBRO- SPINAL    FEVER. 

epinal  fever  has  remained  in  that  city  since  its  introduction  in  1863,  a 
period  of  twenty  years,  the  annual  deaths  produced  by  it  varying  be- 
tween 36,  the  minimum,  in  1869  and  1870,  and  384,  the  maximum,  in 
1864.  In  Providence,  also,  as  appears  from  Dr.  Snow's  reports,  cere- 
bro-spinal  fever  has  caused  annually  more  or  fewer  deaths  since  1871. 
Therefore,  we  repeat,  this  fact  may  be  added  to  the  sum  of  our  knowl- 
edge of  this  disease,  that  once  gaining  a  lodgement,  where  the  condi- 
tions are  favorable  for  it,  as  in  a  large  city,  it  may  become  established 
and  remain  there  an  indefinite  time. 

Anatomical  Characters. — I  have  notes  of  the  post-mortem  appear- 
ances in  76  cases,  published  chiefly  in  British  and  American  journals; 
29  died  within  the  first  three  days,  28  between  the  third  and  twenty-first 
days,  and  the  duration  of  the  remaining  11  was  unknown.  These 
records  furnish  the  data  for  the  following  remarks: 

The  blood  undergoes  changes  vvhich  are  due  in  part  to  the  inflam- 
matory and  in  part  to  the  constitutional  and  asthenic  nature  of  the  dis- 
ease. The  proportion  of  fibrin  is  increased  in  cases  that  are  not  speedily 
fatal,  as  it  ordinarily  is  in  idiopathic  intiammations.  Analyses  of  the 
blood  by  Ames,  Tourdes,  and  Maillot  show  a  variable  proportion  of 
fibrin  from  3.40  to  more  than  six  parts  in  1000.  In  sthenic  cases 
accompanied  by  a  pretty  general  meningitis,  cerebral  and  spinal,  there 
is,  after  the  fever  has  continued  some  days,  the  maximum  amount  of 
fibrin,  while  in  the  asthenic  and  suddenly  fatal  cases,  with  inflammation 
slight,  or  in  its  commencement,  the  fibrin  is  but  little  increased.  The 
most  common  abnormal  aj)pearance  of  the  blood  observed  at  autopsies  is 
a  dark  color  with  unusual  fluidity  and  the  presence  of  dark  soft  clots. 
Exceptionally  bubbles  of  gas  have  been  observed  in  the  large  vessels, 
and  the  cavities  of  the  heart.  An  unusually  dark  color  of  the  blood, 
small  and  soft  dark  clots,  and  the  presence  of  gas-bubbles,  when  only  a 
few  hours  have  elapsed  after  death,  indicate  a  malignant  form  of  the  dis- 
ease, ill  Avliich  the  blood  is  eai'ly  and  profoundly  altered.  In  certain 
cases  this  fluid  is  not  so  changed  as  to  attract  attention  from  its  appear- 
ance. The  points  or  patches  of  extravasated  blood  which  are  observed 
in  and  under  the  skin  during  life  in  some  patients  usually  remain  in  the 
cadaver.  When  an  incision  is  made  through  them  the  blood  is  seen  to 
have  been  extravasated  not  only  in  the  layers  of  the  skin,  but  also  in 
the  su])Cutaneous  connective  tissue.  Extravasations  of  small  extent  are 
also  sometimes  observed  upon  and  in  thoracic  and  abdominal  organs. 

In  those  who  die  after  a  sickness  of  a  few  hours  or  days,  namely,  in 
the  stage  of  acute  inflammatory  congestion,  the  cranial  sinuses  are  found 
engorged  Avith  blood,  and  containing  soft  dark  clots.  The  meninges 
enveloping  the  brain  are  also  intensely  hypernemic,  in  their  entire  extent 
in  most  cadavers;  Ijut  in  some  cases  the  hyperaemia  is  limited  to  a  por- 
tion of  the  meninges,  Avhilo  other  portions  appear  nearly  normal.  In 
those  cases  which  end  fatally  Avithin  a  few  hours,  this  hyperoomia  ia 
ordinarily  the  only  lesion  of  the  meninges;  but  if  the  case  be  more  pro- 
tracted, serum  and  fibrin  are  soon  exuded  from  the  vessels  into  the 
meshes  of  the  pia  mater,  and  underneath  this  membrane,  over  the  sur- 
face of  the  brain.  Pus-cells  also  occur  mixed  with  the  fibrin,  sometimes 
so  few  as  to  be  discovered  only  with  the  microscope,  but  in  other  cases; 


AXATOMICAL    CHARACTERS.  383 

in  such  quantity  as  to  be  much  in  excess  of  the  fibrin,  and  be  readily 
detected  by  the  naked  eye.  Pus,  Avhich  in  these  cases  probably  consists 
of  white  blood-corpuscles  which  have  escaped  with  the  fibrin  from  the 
meningeal  vessels,  sometimes  appears  early  in  the  attack.  Thus  Dr. 
Gordon'  relates  the  history  of  a  case  in  which  death  occurred  after  a 
sickness  of  five  hours,  and  a  purulent  greenish  exudation  had  already 
occurred  in  places  under  the  meninges.  The  exudation  of  fibrin  also 
begins  early.  In  a  case  of  thirty  hours'  duration,  published  by  Dr. 
William  Frothingham,^  and  in  another  of  one  day's  dui'ation,  published 
by  Dr.  Haverty,^  exudation  of  fibrin  had  already  occurred  in  and  under 
the  pia  mater.  The  arachnoid  soon  loses  its  transparency  and  polish, 
and  presents  a  cloudy  appearance  over  a  greater  or  less  extent  of  its 
surface.  Tiiis  cloudiness  is  usually  greatest  along  the  course  of  the 
vessels  in  the  sulci  and  depressions,  and  where  the  fibrinous  exudation 
is  greatest,  but  it  occurs  also  where  no  such  exudation  is  apparent  to 
the  naked  eye.  Dr.  Gordon*  describes  a  case  of  only  eight  hours' 
duration,  in  which  the  arachnoid  was  already  opaque  at  the  vertex,  but 
of  normal  appearance  at  the  base  of  the  brain,  though  the  vessels  of  the 
pia  mater  Avere  everywhere  greatly  congested. 

The  exudation — serous,  fibrinous,  and  purulent — occurs  as  in  other 
forms  of  meningitis,  within  the  meshes  of  the  pia  mater,  and  underneath 
this  membrane  over  the  surface  of  the  brain.  The  fibrin  is  raised  from 
the  surface  of  the  brain  with  the  meninges.  It  is  most  abundant  in  the 
inter-gyral  spaces,  around  the  course  of  the  vessels,  over  and  around  the 
optic  commissure,  the  pons  Varolii,  the  cerebellum,  medulla  oblongata, 
and  along  the  Sylvian  fissures.  It  is  most  abundant  in  the  depressions, 
where  it  sometimes  has  the  thickness  of  ^  to  ^  of  an  inch,  but  it  often 
extends  over  the  convolutions  so  as  to  conceal  them  from  view. 

Most  other  forms  of  meningitis  have  a  local  cause,  and  are  therefore 
limited  to  a  small  extent  of  the  meninges,  as,  for  example,  meningitis 
from  tubercles  or  caries  of  the  petrous  ])ortion  of  the  temporal  bone,  in 
both  of  which  it  is  commonly  limited  to  the  base  of  the  brain ;  or  from 
accidents,  when  the  meningitis  commonly  occurs  upon  the  side  or  sum- 
mit of  the  brain.  Tlie  meningitis  of  cerebro-spinal  fever,  on  the  other 
hand,  having  a  general  or-  constitutional  cause,  occurs  with  nearly 
equal  frequency  upon  all  parts  of  the  meningeal  surface,  except  that  it 
is  perhaps  most  severe  in  the  depressions,  where  the  vascular  supply  is 
greatest.  In  cases  of  great  severity  the  inflammatory  exudation,  fibrin- 
ous or  purulent,  or  both,  may  cover  nearly  or  quite  the  entire  surface 
of  the  brain.  Thus  in  the  case  of  a  negro,  thirty-five  years  old,  only 
four  days  sick,  whose  body  was  examined  in  Bellevue  Hospital  on  May 
30,  1872,  the  record  states  that  tlierewas  a  purulent  exudation  over  the 
entire  surface  of  the  cerebrum  and  cerebellum.  The  quantity  of  serous 
exudation  varies  according  to  the  duration  of  the  disease  and  amount  of 
congestion.  In  some  the  quantity  is  so  small  as  scarcely  to  attract 
attention,  but  in  other  instances,  especially  when  the  disease  is  protracted, 
it  is  large.     In  a  case  reported  by  Dr.   Moorman,*  it  is  statc<l  that 

'  Dublin  Quarterly  Joiirn"..  18R6.  J  Amut.  Mc<].  Times,  A|iril  30,  18G4. 

*  D.il)lin  Quarterly  Journ.,  18G7.  *  Ibid.,  1H«0. 

'  Ameritun  Juuinal  cf  llic  ^[edical  Sciences   October,  1866. 


884  CEREBRO-SPIXAL    FEVER. 

about  three  pints  of  turbid  scrum  escaped  from  the  cranial  cavity  in 
attempting  to  remove  the  brain ;  but  as  there  ^vas  no  measurement  the 
statement  may  be  somcAvhat  exaggerated. 

In  those  who  die  at  an  early  stage  of  the  attack,  the  vessels  of  the 
brain,  like  those  of  the  meninges,  are  hyperremic,  so  that  numerous 
"  puncta  vasculosa  "  appear  upon  its  incised  surface.  At  a  later  ]ieriod 
this  hypertemia,  like  that  of  the  meninges,  may  disappear.  If  there  be 
much  effusion  of  serum  within  the  ventricles,  and  over  the  surface  of  the 
brain,  the  convolutions  are  liable  to  be  flattened,  and  the  pressure  may 
be  so  great  that  the  amount  of  blood  circulating  in  the  brain  is  reduced 
below  the  normal  quantit}'.  Thus  in  the  case  of  a  child  of  three  years, 
who  lived  sixteen  days,  and  was  examined  after  death  by  Burdon-San- 
derson,  the  ventricles  contained  a  large  amount  of  turbid  serum,  and  the 
brain-substance  was  everywhere  pale  and  anaemic. 

Cerebral  ramollissemejit  occurs  in  certain  cases.  At  one  of  the  ex- 
aminations in  Charity  Hospital,  the  patient  having  been  only  three  days 
sick,  the  brain  Avas  found  much  softened.  The  dissection  was  made 
seven  houi's  after  death,  so  that  the  softeninsr  could  not  have  been  the 
result  of  decomposition.  At  one  of  the  post-mortem  examiruitions  in 
Belleviie  Hospital,  softening  of  the  fornix,  corpus  callosum,  and  septum 
lucidum  was  observed,  and  in  another,  softening  in  the  neighborhood  of 
the  subarachnoid  space.  In  a  case  related  by  Dr.  Moorman'  it  is 
stated  that  portions  of  the  brain,  medulla  oblongata,  and  pons  Varolii 
Avere  softened.  In  a  case  observed  by  Dr.  Upham  softening  of  the 
superior  portion  of  the  left  cerebral  hemispliere  had  occurred.  Occa- 
sionally the  Avhole  brain  is  somewhat  softened.  Burdon-iSanderson, 
Russell,  and  Githens  each  relate  such  a  case.  Moreover,  the  walls  of 
the  lateral  ventricles  are  ordinarily  more  or  less  softened  in  fatal  cases 
of  cerebro-spinal  fever,  as  they  are  in  the  usual  forms  of  meningitis.  In 
rare  instances  the  brain  is  oedematous,  as  in  a  case  published  by  Dr. 
Hutchinson.^  In  this  case  the  patient  Avas  oidy  four  days  sick,  and  the 
whole  brain  was  oedematous,  serum  escaping  from  its  incised  surface. 

The  ventricles  contain  liquid,  in  some  patients  transparent  serum,  in 
others  serum  turbid  and  containing  flocculi  of  fibrin,  or  fibrin  with  pus. 
The  liquids  in  the  different  ventricles,  since  they  intercommunicate,  are 
the  same.  The  choroid  plexus  is  either  injected  or  it  is  infiltrated  Avith 
filu'in  and  pus.  With  tlie  abatement  ot  the  inflammation  absorption 
commences.  The  serum,  from  its  nature,  is  readily  absorbed,  and  the 
pus  and  fibrin  more  sloAvly  by  fatty  degeneration  and  liquefaction. 
Occasionally  the  serum  remains,  and  chronic  hydrocephalus  results. 
An  infant  Avho  contracted  the  disease  at  the  age  of  five  months,  and 
appeared  to  be  convalescent,  had,  tAvo  months  subsequently,  great  ])rom- 
inence  of  the  anterior  fontanelle,  and  other  symptoms  Avhich  indicate 
the  presence  of  a  considerable  amount  of  effusion  Avithin  the  cranium. 
In  another  case,  one  year  afterAvard,  examination  shoAved  the  enlarge- 
ment of  the  head  and  prominence  of  the  fontanelle  which  characterize 
chronic  hydrocephalus.  A  boy  of  ten  years,  treated  in  RooscA'clt  Hos- 
pital in  1878,  died  three  months  after  the  commencement  of  cerebro- 

*  Amerifitn  Journal  of  the  Medical  Sciences,  October,  1866. 
2  Ibid.,  July,  1866. 


AXATOMICAL    CHARACTERS,  385 

spinal  fever.  The  records  of  the  autopsy  state:  "Body  a  skeleton; 
brain,  dura  mater  and  pia  mater  appear  normal,  except  a  little  thicken- 
intr  of  latter  at  base  of  brain;  ventricles  much  enlarged  and  full  of  clear 
serum;  surface  of  walls  of  ventricles  appears  normal,  but  is  soft;  sjunal 
cord  and  membranes  apparently  normal;  heart,  lungs,  stomach,  and  in- 
testines normal;  liver  congested;  kidneys  pale."  In  this  case,  there- 
fore, all  the  other  lesions  of  the  cerebro-spinal  axis,  except  the  serous 
effusion,  had  nearly  disappeared.  No  post-mortem  examinations,  so  far 
as  I  am  aware,  have  yet  revealed  the  state  of  the  brain  and  its  meninsres 
in  those  who  have  had  this  malady  at  some  former  time  and  have  fully 
recovered,  whether  there  may  not  be  some  traces  of  it  wliich  are  perma- 
nent, as  opacity  or  adhesions. 

The  remarks  made  in  reference  to  the  cerebral  apply,  for  the  most 
part,  also,  to  the  spinal  meninges.  There  is  at  first  intense  hyperscmia 
of  the  membranes,  usually  over  the  entire  surfjice  of  the  cord,  soon  fol- 
lowed by  fibrinous,  purulent,  and  serous  exudation  in  the  meshes  of  the 
pia  mater,  and  underneath  this  membrane.  This  exudation  is  some- 
times confined  to  a  portion  of  the  meninges,  more  frequently  that  cover- 
ing the  posterior  than  anterior  aspect  of  the  cord,  and  when  it  is  general 
it  is  ordinarily  thicker  posteriorly  than  anteriorly.  In  severe  cases 
nearly  or  rpiite  the  entire  spinal  pia  mater  may  be  infiltrated  l)y  inllara- 
matory  products.  Thus  in  case  of  an  infant  that  died  of  cerebro-spinal 
fever  at  the  age  of  ten  weeks,  in  the  service  of  Dr.  H.  D.  Cluipin,  in 
the  out-door  department  at  Bellevue,  the  entire  spinal  cord  Avas  covered 
by  a  fibrino-purulent  exudation,  except  a  space  about  six  lines  in  extent 
upon  the  anterior  surfoce. 

At  the  meeting  of  the  New  York  Pathological  Society,  ^Nlarch  23, 
1881,  Dr.  G.  L.  Peabody  presented  the  specimens  from  the  ])ody  of  a 
patient,  aged  nineteen  years,  who  died  on  the  tenth  day  of  cerebro-spinal 
fever.  The  exudation  extended  over  the  base  of  the  brain,  both  lobes  of 
the  cerebellum,  and  covered  completely  the  cord  to  the  cauda equina,  being, 
as  usual,  thickest  upon  the  posterior  surface.  In  some  patients  the 
spinal  meningitis  is  severe,  while  the  cerebral  is  slight,  so  that  the  symp- 
toms referable  to  the  spinal  axis  predominate,  such  as  pain  in  the  back 
and  limbs,  and  opisthotonos.  The  exudation  may  have  the  usual  ajipear- 
ance  of  fibrin  and  pus,  but  it  is  sometimes  greenish  and  sometimes  blood- 
stained. Small  extravasations  of  blood  also  occur  as  a  result  of  the 
hypememia,  and  in  one  case  related  by  Burdon-Sandcrson  it  is  stated  that 
there  was  a  layer  of  blood  one-eighth  of  an  incli  thick  over  the  whole 
cord  below  the  bronchial  swelling.  In  post-mortem  examinations  the 
central  canal  of  the  cord  has  usually  been  overlooked.  Zicinssen  relates 
a  case,  and  Gordon  another,  in  which  it  was  dilated  and  filled  with  puru- 
lent fluid.  The  anatomical  changes  Avhich  have  been  observed  in  the 
cord  itself  have  been  injection  of  its  vessels  in  recent  cases,  and  occa- 
sional softening  of  portions.  Thus  in  a  case  which  was  examined  in 
Bellevue  Tlospital,  A[)ril  13,  1872,  it  is  stated  that  there  was  softening 
of  the  cord  in  the  upper  part  of  the  dorsal  region.  In  most  of  the  ex- 
aminations the  only  abnormal  appearance  detected  in  the  cord  wns  hyper- 
ieuiia,  but  in  a  considerable  proportion  of  cases  the  records  state  that  the 
substance  of  the  cord  appeared  normal. 

25 


386  CEREBRO- SPINAL    FEVER. 

Professor  AVm.  II.  Welch,  of  Jolins  Hopkins  University,  lias  recently 
commiinicutjed  to  uie  the  following  results  of  his  examinations  "when 
curator  to  Bellevue  Hospital: 

"  I  have  records  of  eight  autopsies  "which  I  have  made  upon  cases  of 
cerebro-spinal  meningitis,  and  in  six  cases  I  have  examined,  microscopic- 
ally, portions  of  the  hardened  brain  and  cord.  Post-mortem  rigidity  is 
usually  "well  marked  and  continues  for  a  long  time  after  death.  Upon 
removal  of  the  skull-cap,  which  is  often  hyperi^mic,  the  dura  mater 
appears  tense,  and  usually  more  or  less  congested.  The  sinuses  contain 
loose,  dark  red  coagula,  and  some  fluid  blood.  In  one  case  I  found  a 
recently  formed  grayish-red  ante-mortem  thrombus  in  the  left  lateral  sinus. 
The  subdural  s})ace  is  usually  free  from  inflammatory  exudation,  but 
occasionally  a  slight  fibrino-purulent  exudation  is  found  on  the  outer 
surface  of  the  arachnoid  membrane.  The  pia  mater  is  generally  liyper- 
semic,  and  frequently  it  contains  small  ecchymoses.  An  exudation  is 
present  in  the  subarachnoid  spaces,  over  both  the  convexity  and  the 
base  of  the  brain,  most  abundantly,  as  a  rule,  at  the  base.  Over  the 
convexity  the  exudation  appears  in  the  form  of  greenish-yellow  streaks 
along  the  veins  between  the  gyri.  At  the  base  the  exudation  accumu- 
lates in  the  subarachnoid  cisterns,  such  as  those  of  the  Sylvian  fissure, 
of  the  optic  chiasm,  of  the  intercrural  space,  of  the  under  surface  of  the 
cerebellum,  and  along  the  basilar  artery.  The  cranial  nerve-trunks 
may  be  enveloped  in  a  ])urulent  exudate  as  they  emerge  from  the  brain. 
The  fluid  in  the  ventricles  may  or  may  not  be  increased  in  amount,  but 
is  usually  turbid  from  admixture  of  pus-cells.  The  choroid  plexuses 
are  often  swollen  and  opaque. 

"  The  substance  of  the  brain  is  usually  hypersemic,  and  frequently 
contains  punctate  ecchymoses,  "which  may  occur  in  groups.  Small  foci 
of  softening  maybe  formed  before  death,  but  extensive  diffuse  softening, 
particularly  that  around  dilated  ventricles  (hydrocephalic  softening)  is 
probably  cadaveric,  and  due  to  imbibition  of  serum,  although  it  may 
form  within  a  short  time  after  death. 

"  The  inflammatory  exudation  occupies  likewise  the  subarachnoid 
space  over  the  cord.  The  exudation  may  surround  the  posterior  nerve- 
roots  for  a  distance  from  the  cord.  Microscopic  examination  shows  that 
the  exudation  is  composed  of  serum,  fibrin,  pus-cells,  and  red  blood- 
corpuscles.  Usually  the  exudation  is  distinctly  purulent,  being  of  a 
greenish-yellow  color,  but  it  may  be  predominantly  serous  in  character. 
The  pus-cells  are  accumulated  around  the  small  veins  and  capillaries. 
I  have  found  the  ependyma  of  the  fourth  ventricle  richly  infiltrated  Avith 
pus-cells,  which  here  as  well  as  elscAvhere  are  probably  emigrated  white 
blood-corpuscles.  The  connective  tissue  cells  of  the  pia-arachnoid  mem- 
brane are  swollen  and  granular.  The  lymph  spaces  around  the  blood- 
vessels in  the  cerebral  cortex  are  often  filled  with  jjus-cells.  The  com- 
munication between  these  perivascular  spaces  and  the  subarachnoid  spaces 
renders  easy  the  passage  of  wandering  cells  from  the  pia  mater  into  the 
cortex.  There  may  also  be  found  an  increased  number  of  lymphoid 
cells  in  the  periganglionic  spaces.  In  a  similar  manner  the  sheaths  of 
the  bloodvessels  and  the  pial  processes  in  the  spinal  cord  may  be  in- 
vaded by  pus-cells. 


PROGNOSIS.  387 

"  In  one  of  my  cases  the  symptoms  of  the  disease  are  said  to  have 
existed  for  only  twelve  hours  before  death.  Here  there  -was  an  excess  of 
serum  in  the  cerebral  and  spinal  subarachnoid  spaces.  The  serum  was 
moderately  turbid.  The  microscope  showed  a  more  abundant  exudation 
of  pus-cells  than  there  appeared  to  be  from  the  gross  appearances.  The 
substance  of  the  brain  Avas  pale  and  edematous,  nor  was  there  marked 
couf^estion  of  the  meninges." 

No  constant  or  uniform  lesions  occur  in  the  organs  of  the  trunk,  and 
those  observed  are  not  distinctive  of  this  disease.  Hypostatic  conges- 
tion of  the  lungs,  bi'onchitis,  atelectasis,  and  broncho-pneumonia  are 
common.  Pleuritic,  endocardial,  and  pericardial  inflammations  have 
occasionally  been  observed,  but  are  rare.  Effusion  of  serum,  sometimes 
blood-stained,  occasionally  occurs  in  the  pleural  and  other  serous  cavities. 
The  auricles  and  ventricles  of  the  heart,  as  already  stated,  contain  more 
or  less  blood,  with  soft  dark  clots  in  the  more  malignant  and  rapidly 
fatal  cases,  but  larger  and  firmer  in  those  which  have  been  more  pro- 
tracted. Tlie  spleen  is  enlarged  in  less  than  half  the  patients.  The 
absence  of  uniformity  as  regards  the  state  of  the  spleen,  the  fact  that  in 
many  it  undergoes  no  appreciable  change,  is  important,  since  this  organ 
is  so  generally  enlarged  and  softened  in  the  infectious  diseases.  The 
stomach,  intestines,  and  liver  are  sometimes  more  or  less  congested,  but 
in  other  cases  their  appearance  is  normal.  The  agminate  and  solitary 
glands  of  the  intestines  have  ordinarily  been  overlooked,  but  in  certain 
cases  they  have  been  found  prominent.  The  kidneys  in  some  exhibit  the 
lesions  of  nephritis.  In  one  of  the  eight  autopsies  made  by  Professor 
Welch  acute  diffuse  nephritis  had  been  present,  as  shown  by  the  state  of 
the  kidneys.  In  the  case  of  a  child  of  nine  years,  treated  l)y  Dr.  F.  A. 
Burrall,  in  the  Presbyterian  Hospital,  the  urine  was  very  albuminous 
and  the  kidneys  presented  a  fatty  appearance.  xVnatomical  changes  in 
these  organs,  however,  are  not  common,  unless  in  slight  degree,  so  that 
in  most  patients  their  function  is  fully  and  properly  performed. 

PiiOGXOSis. — Cerebro-spinal  fever  is  justly  regarded  as  one  of  the 
most  dangerous  maladies  of  cliildhood.  It  is  dreaded  not  only  on  ac- 
count of  the  great  mortality  which  attends  it,  but  on  account  also  of  its 
protracted  course,  the  sulfering  which  it  causes,  the  possible  permanent 
injury  of  the  important  organ  which  is  chiefly  involved,  and  the  not 
infrequent  irreparable  damage  Avhich  the  eye  and  ear  sustain. 

I  liave  the  records  of  the  result  in  52  cases  which  I  attended  or  saw 
in  consultation  in  the  epidemic  of  1<S72.  Of  these  just  one-half  recov- 
ered. Sixteen  of  the  twenty-six  who  died  were  hopelessly  comatose 
within  the  first  seven  days,  most  of  them  dying  within  that  time,  and 
some  even  on  the  first  and  second  days,  while  others  of  the  sixteen  lin- 
gered into  the  second  week  and  died  without  any  sign  of  returning 
consciousness.  The  remaining  ten,  who  subsequently  died,  but  did  not 
become  comatose  in  the  first  week,  were  nevertheless  seriously  sick 
from  the  first  day,  but  their  symptoms,  though  severe,  Avere  not  such 
as  necessarily  indicated  a  fatal  result,  so  that  there  was  some  expecta- 
tion of  a  favorable  ending  till  near  death,  which  occurred  for  the  most 
part  from  asthenia.  One  succumbed  to  purpura  htmorrhagica,  the 
hemorrhages  occurring  from  the  mucous  surfaces,  and  who  died  after  a 


388  CEREBRO-SPINAL    FEVER. 

sickness  of  more  tlian  two  months,  in  a  state  of  extreme  emaciation  and 
prostration.  The  twenty-six  who  recovered  convalesced  slowly  and 
usually  after  many  fluctuations.  Their  highest  tem])eraturc  and  most 
severe  and  dangerous  symptoms  occurred  in  the  first  week.  Most  of 
them  were  several  weeks  under  observation  and  treatment  before  they 
sufficiently  recovered  to  be  out  of  danger.  The  statistics  of  this  epi- 
demic therefore  show,  and  the  same  is  true  of  other  epidemics,  that  the 
first  week  is  the  time  of  greatest  danger,  and  if  no  fatal  symptoms  are 
develoited  during  this  Aveek  recovery  is  probable  with  proper  therapeutic 
measures  and  kiiul,  intelligent,  and  efficient  nursing,  the  latter  of  which 
is  very  important. 

Since  the  epidemic  of  1872  I  have  treated,  or  seen  in  considtation, 
35  cases  that  I  was  able  to  follow  to  the  close,  most  of  tliem  in  the  last 
four  years.  Of  these  19  recovered  and  16  died.  Of  the  10  fatal  cases 
8  died  in  the  first  week,  5  in  the  second  week,  1  on  the  twenty-fifth 
day,  1  on  the  thirty-first  day,  and  1  in  the  sixteenth  week.  This  last 
patient,  a  boy  of  ten  years,  would,  in  my  opinion,  have  recovered  with 
better  nursing.  His  death  occurred  from  large  bedsores  Avhich  ex- 
tended to  the  bones,  produced,  though  attended  by  his  mother,  by  l.ying 
a  long  time  in  one  position  on  a  hard  bed,  when  he  Avas  too  weak  to 
move,  and  often  with  soiled  bedclothes  underneath  him. 

There  is  probably  no  disease  which  falsifies  the  predictions  of  the 
physician  more  frequently  than  cerebro-spinal  fever.  This  is  due  partly 
to  the  severity  of  the  cerebral  symptoms  in  the  commencement,  Avhich, 
did  they  occur  in  other  forms  of  meningitis  Avith  wliich  he  is  more 
familiar,  Avould  justify  an  unfavorable  prognosis,  and  partly  to  the 
remissions  and  exacerbations,  the  occurrence  alternately  of  symptoms 
of  apparent  convalescence  and  recrudescence  or  relapse,  Avhich  char- 
acterize t^is  course  of  this  malady.  Grave  initial  symptoms,  Avhich 
may  appear  to  have  a  fiital  augury,  are  often  folloAved  by  such  a  remis- 
sion that  all  danger  seems  past,  and  in  a  fcAV  hours  later,  perhaps,  the 
symptoms  are  nearly  or  quite  as  grave  as  at  first. 

Under  the  age  of  five  years,  and  over  that  of  thirty,  the  prognosis  is 
less  favorable  than  betAveen  these  ages.  An  abrupt  and  violent  com- 
mencement, profound  stupor,  convulsions,  active  delirium,  and  great 
elevaticm  of  temperature,  are  symptoms  Avhich  should  excite  solicitude 
and  render  the  prognosis  guarded.  If  the  temperature  remain  above 
105°  death  is  probable,  even  with  moderate  stupor.  Numerous  and 
large  petechial  eruptions  sIioav  a  profoiuidly  altered  state  of  the  blood, 
and  are  therefore  a  bad  prognostic,  and  so  is  continued  albuminuria, 
since  it  shoAvs  great  blood  change,  or  nephritis,  while  other  organs  than 
the  kidneys  are  probably  also  involved.  In  one  case,  a  boy,  Avliom  I 
examined  nearly  a  year  after  the  cerebro-spinal  fever,  the  kidneys 
Avcre  still  afiected.  He  had  anasarca  of  the  face  and  extremities,  with 
albuminuria.  Chronic  Bright's  disease  had  occurred  from  the  acute 
nephritis,  Avhich  complicated  cerebro-spinal  fever.  Profoimd  stupor, 
though  a  dangerous  symptom,  is  not  necessarily  fatal  so  long  as  the 
patient  can  be  aroused  to  partial  consciousness  and  the  pupils  are 
responsive  to  light ;  so  long  as  it  does  not  pass  into  actual  coma  it  is 


DIAGNOSIS.  389 

less  dangerous  than  active  or  maniacal  delirium,  Avbicli  is  apt  to  even- 
tuatj  in  this  coma. 

A  mild  commencement,  "with  general  mildness  of  symptoms,  as  the 
ability  to  comprehend  and  answer  questions,  moderate  pain  and  muscu- 
lar rigidity,  some  appetite,  moderate  emaciation,  little  vomiting,  etc., 
justify  a  favorable  prognosis,  but  even  in  such  cases  it  should  be  guarded 
till  convalescence  is  fully  established. 

"We  may  repeat  and  emphasize  the  important  fact  shown  by  the  above 
statistics,  that  patients  Avho  live  till  the  close  of  the  second  week  Avith- 
out  serious  complications  will  probably  recover.  The  danger  after  this 
period  is,  in  most  instances,  from  exhaustion  and  feeble  action  of  the 
heart,  resulting  from  the  .impaired  nutrition  and  protracted  course  of 
the  disease. 

Complications,  which  most  frequently  pertain  to  the  lungs,  increase 
greatly  the  gravity  of  many  cases  and  contribute  to  the  fatal  ending. 
The  fact  that  Webber,  in  his  prize  essay,  describes  a  variety  of  cerebro- 
spinal fever  which  he  designates  pneumonic,  and  that  those  who  make 
post-mortem  examinations  find  that  "  oedema,  hypostatic  congestion  of 
the  lungs,  bronchitis,  atelectasis,  and  broncho-pneumonia,  are  extremely 
common  lesions  in  cercbro-spinal  meningitis"  (Welch),  indicates  a 
source  of  danger  in  addition  to  that  located  in  the  cerebro-spinal 
system.  One  close  ol)server  of  an  epidemic  writes :  "  In  all  the  fatal 
cases  which  came  under  my  notice,  the  most  prominent  symptoms  which 
preceded  death  were  those  which  indicate  impairment  and  perversion  of 
the  respiratory  functions.  As  the  breathing  became  more  hurried  and 
difficult,  the  general  depression  became  more  intense,  the  pulse  became 
weaker  and  (juicker,  and  the  temperature  of  the  skin  more  elevated." 

Parenchymatous  degeneration  of  the  liver  and  kidneys  is  another 
serious  complication.  The  kidneys  are  probably  more  frequently,  and 
to  a  greater  extent,  diseased  than  the  liver.  Acute  diffuse  nephritis 
was  present  in  one  of  the  eight  cases  examined  after  death  by  Prof. 
Welch.  In  the  Reime  Mcdl'mh  for  June  o,  1882,  M.  Ernest  Gaudier 
published  the  case  of  a  fenuvle  who  died  comatose  on  the  sixth  day  of 
cerebro-spinal  fever.  Examination  of  the  urine  bad  reveale<l  the  pres- 
ence of  "retractile  albumen  of  Prof  ]5oucliard,  attributable  to  renal 
lesions,  and  non-retractile  albumen,  considered  as  an  indication  of  some 
general  infection  of  the  system."  Microscopic  examination  of  the 
kidneys  "showed  considerable  swelling  and  granular  degeneration  of 
the  renal  epithelial  cells,  with  effusion  of  granular  matter  Avithin  the 
111  men  of  the  tubules.  We  have  seen  from  the  case  alluded  to  above 
that  the  renal  complication  may  persist  and  become  chronic.  Those 
who  fully  recover  often  exhibit  symptoms  usually  of  a  nervous  char- 
acter, as  irritability  of  disposition,  headache,  etc.,  for  months  after  con- 
valescence is  established. 

DtACNosrs. — ('ere])ro-s]iiii:il  fever,  on  account  of  the  nature  and 
severity  of  its  symptoms  and  the  suddenness  of  its  onset,  may  be  mis- 
taken for  scarlet  fever,  and  vice  vcrail.  In  one  instance,  to  my  knowl- 
edge, this  mistake  was'  made.  High  febrile  movement,  vomiting,  eon- 
vidsions,  and  stupor,  are  common  in  the  commencenu'nt  of  scai-let  fever, 
and  the  same  symptoms  connnonly  usher  in  the  severer  forms  of  cere- 


390  CEREBRO-SPINAL    FEVEE. 

bro-spinal  fever.  It  Mill  aid  in  diagnosis  to  ascertain  whether  there  he 
redness  of  the  fauces,  for  this  is  present  in  the  commencement  of  scarlet 
fever,  and  in  a  lew  hours  later  the  characteristic  efllorescence  appears 
on  the  skin. 

The  diagnosis  of  cerebro-spinal  fever  fiom  the  common  forms  of 
meningitis  is  ordinarily  not  difficult,  for  while  in  the  former  the  maxi- 
mum intensity  of  symptoms  occurs  in  the  first  days,  in  the  latter  there 
is  a  gradual  and  progressive  increase  of  symptoms,  from  a  comparatively 
mild  commencement.  Moreover,  cases  of  ordinary  or  sporadic  menin- 
gitis occurring  at  the  age  when  cerebro-spinal  fever  is  most  frequent, 
are  commonly  secondary,  being  due  to  tubercles,  caries  of  the  petrous 
portion  of  the  temporal  •  bone,  or  other  lesion,  and  are  therefore  pre- 
ceded and  accompanied  by  symptoms  which  are  directly  referable  to 
the  primary  disease.  We  have  seen  how  different  it  is  in  cerebro-spinal 
fever,  which  in  most  patients  begins  aljruptly  in  a  state  of  previous 
good  health.  Again,  in  cerebro-spinal  fever,  after  the  second  or  third 
day,  hyperaesthesia,  retraction  of  the  head,  and  other  characteristic 
symptoms  occur,  which  are  either  not  present  or  are  much  less  pro- 
nounced in  ordinary  meningitis.  Some  of  the  milder  cases  of  cerebro- 
spinal fever  might  be  mistaken  for  hysteria,  but  the  pain  in  the  head 
and  elsewhere,  muscular  rigidity,  and  especially  the  occurrence  of  more 
or  less  febrile  movement,  enable  us  to  make  the  diagnosis.  Continued 
fever,  typhus  or  typhoid,  resembles  cerebro-spinal  fever  in  certain  par- 
ticulars, but  it  lacks  the  muscular  contraction  and  rigidity  which  char- 
acterize the  latter.  It  does  not  usually  begin  so  abruptly,  with  such 
severe  symptoms,  especially  such  severe  headache,  has  less  marked 
fluctuations,  and  a  more  definite  duration.  These  facts,  in  connection 
with  the  character  of  the  prevailing  epidemics,  will  enable  us  to  make 
the  diagnosis.  In  one  instance  commencing  retro-pharyngeal  abscess, 
probably  associated  with  vertebral  caries,  Avas  at  first  mistaken  by  me 
for  cerebro-spinal  fever.  The  patient  was  an  infant,  had  a  tempera- 
ture of  104°,  stiffness  of  the  neck  with  some  retraction  of  the  head,  and 
cried  from  pain  wdien  the  head  was  brought  forward.  The  speedy 
occurrence  of  two  large  abscesses  in  other  parts  of  the  system,  difficult 
deglutition  and  noisy  respiration,  led  to  a  digital  exploration  of  the 
fauces,  Avhen  the  abscess  Avas  found  and  lanced. 

Trkatment. — Since  in  epidemics  of  cerebro-spinal  fever  cases  are 
more  frequent  and  severe  where  anti-hygienic  conditions  exist,  it  is  evi- 
dent that  measures  looking  to  the  removal  of  such  conditions,  measures 
designed  to  procure  pure  air  in  the  domicile,  wholesome  diet,  and  a 
quiet  and  regular  mode  of  life — in  fine,  measures  designed  to  produce 
the  highest  degree  of  health — are  of  the  first  importance  for  the  preven- 
tion of  the  disease.  Cleanliness  of  the  streets  and  areas,  as  well  as 
apartments,  perfect  sewerage  and  drainage,  the  prompt  removal  of  all 
refuse  matter,  avoidance  of  over-crowding;  in  a  word,  the  strict  observ- 
ance of  sanitary  requirements  in  every  particular,  will,  there  can  be 
little  doubt  from  Avliat  Ave  knoAv  of  the  causation  and  nature  of  cerebro- 
spinal fever,  diminish  the  number  and  severity  of  the  cases.  The  avoid- 
ance of  filtigne  and  overAvork,  of  mental  excitement,  the  use  of  plain 
and  wholesome  diet,  sufficient  sleep,  the  utmost  regularity  in  the  mode 


CURATIVE    TREATMENT.  391 

of  life  with  tlie  least  possible  exposure  to  depressing  agencies,  are  the 
important  preventive  measures  which  should  be  recommended  wherever 
an  epidemic  of  cerebro-spinal  fever  is  occurring. 

It  is  probable  that  the  young  man  who,  still  weak  from  an  attack  of 
typhoid  fever,  applied  himself  closely  to  his  business,  of  a  perplexing 
nature,  which  had  suffered  from  his  absence,  and  in  a  few  days  was 
seized  with  headache  and  vomiting,  and  soon  died  of  this  malady,  Avould 
have  escaped  by  a  more  prolonged  rest,  and  less  mental  excitement  and 
worriment.  It  has  seemed  to  me  that  those  children  whose  cases  are 
embraced  in  my  statistics,  that  left  home  in  the  morning  entirely  Avell, 
and  when  engaged  in  their  studies,  subject  to  the  noise  and  discipline 
of  the  public  schools,  whicli  is  often  too  severe  and  rigorous  for  sensi- 
tive children,  were  attacked  with  this  disease,  would  probably  have 
escaped  in  the  quiet  of  their  own  homes.  The  girl  that,  failing  of  pro- 
motion in  her  school,  returned  home  crying,  and  closely  ap|)lied  herself 
to  her  studies  till  she  was  compelled  to  desist  by  the  severe  headache 
which  ushered  in  cerebro-spinal  fever,  perhaps  would  have  remained 
well  had  her  experiences  in  the  school  been  more  pleasant  and  less 
depressing.  In  a  similar  manner  the  two  children  that  were  attacked 
with  cerebro-spinal  fever  immediately  after  mild  punishments  which 
they  had  received,  but  which  produced  mental  excitement,  perhaps 
would  have  escaped  under  less  severe  family  discipline. 

The  enjoining  of  a  quiet  and  regular  mode  of  life  as  a  preventive 
measure,  during  the  occurrence  of  an  epidemic  of  cerebro-spinal  fever, 
is  not  inconsistent  with  the  theory  that  the  cause  is  a  microorganism. 
It  is  not  unreasonable  to  suppose  that  the  system  may  be  more  or  less 
under  tlie  influence  of  the  specific  principle,  that  this  principle  may 
obtain  lodgement  in  the  blood  or  tissues  without  result  until  some 
exciting  cause  occurs  which  depresses  the  system  and  disturbs  the  func- 
tions, when  the  resisting  power  fails  and  cerebro-spinal  fever  ai)pears; 
just  as  those  exposed  to  Asiatic  cliolera  may  remain  well  until  some 
im|»rudence  in  the  diet  or  the  mode  of  life  causes  an  outbreak  of  the 
mahidy. 

Curative  Thhat.mknt. — In  the  commencement  of  ccrebro-s])inal 
fever,  intense  infiamnuitory  congestion  occurs  of  the  cerebi'al  and  spinal 
meninges,  and  also  to  a  certain  extent  of  the  brain  and  spinal  cord.  As 
regards  treatment,  the  obvious  indication  is  to  reduce  the  hyi)er;VMnia  of 
the  vessels^  as  quickly  as  possible  and  subdue  or  diminish  the  inliaiuma- 
tion.  For  this  purpose  bags  or  bhulders  of  i(-e  should  be  immediately 
ajtplied  over  the  head,  and  to  the  niu-lia,  and  constiintjy  retained  there 
as  long  as  there  is  no  complaint  of  chilliness,  no  marked  diminution  of 
temperature,  and  the  patient  ex)KM'ienceg  some  relief  from  the  intense 
headache  and  other  sym])toms.  JJran  mixed  with  pounded  ice  produces 
a  more  unifonu  coldiu'ss  and  is  sometimes  more  agrceal)lo  to  the  ]).itient 
than  the  ice  alone.  The  baix  or  bai^s  should  be  al)out  one-tliird  full,  so 
as  to  fit  upon  the  head  like  a  cap,  and  the  nurse  should  be  instructed 
to  renew  the  ice  as  soon  as  it  melts.  In  severe  cases,  with  marked  ele- 
vation of  temperature,  it  is  projjcr  to  :ii)ply  cold  over  the  dorsal  and 
lumbar  vertebrtc,  as  well  as  upon  the  head  and  nucha.  A  hot  mustard 
foot-bath  or  a  general  warm  bath  in  those  cases  in  which  convulsions 


S92  CEREBRO-SPINAL    FEVER. 

are  present  or  threatening,  or  tliere  is  delirium  or  great  agitation  or 
severe  j)eriplieral  pains,  is  also  useful,  since  it  lias  a  calmative  effect 
and  acts  as  a  derivative  from  the  hypen^mic  nerve-centres.  One  writer 
states  that  he  obtained  marked  benefit  in  a  case  by  immersing  the  body 
to  the  neck  in  hot  water. 

The  abstraction  of  blood,  usually  by  leeches  applied  to  the  temples, 
behind  the  ears,  or  along  the  spine,  has  been  employed,  but  even  in  the 
commencement  of  the  present  century,  when  it  was  customary  to  bleed 
generally  and  locally  in  the  treatment  of  inflammatory  and  lebrile  dis- 
eases, a  majority  of  the  American  physicians  whose  w  ritings  are  extant 
discountenanced  the  use  of  such  measures  in  the  treatment  of  this  dis- 
ease. Drs.  Strong,  Foot,  and  JNIiner,  though  under  the  influence  of  the 
Broussaian  doctrine,  were  good  observers,  and  they  soon  abandoned  the 
use  of  the  lancet  and  leeches  in  the  treatment  of  these  patients  for  more 
sustaining  measures.  Strong^  states  that  certain  physicians  employed 
venesection  as  a  means  of  relieving  the  internal  congestions,  but  finding 
that  the  pulse  became  more  frequent  after  a  moderate  loss  of  blood, 
they  soon  laid  aside  the  lancet.  Some  experienced  physicians  of  that 
period,  however,  continued  to  recommend  and  practise  depletion,  general 
as  Avell  as  local,  as,  for  example,  Dr.  Gallop,  who  treated  many  cases  in 
Vermont,  in  the  epidemic  of  1811. 

Venesection  in  the  treatment  of  cerebro-spinal  fever  is  universally  dis- 
carded at  the  present  time  in  this  country  and  in  Europe,  but  some  in- 
telligent physicians,  as  Sanderson  and  Niemeyer,  approve  of  local  bleed- 
ing in  certain  cases.  It  is,  in  my  opinion,  after  examining  the  histories 
of  many  cases,  uncertain  whether  the  abstraction  of  blood  should  ever 
be  recommended,  but  if  it  be  prescribed,  it  should  be  on  the  first  day, 
when  the  hyperaemia  is  greatest,  by  the  application  of  only  a  few  leeches 
behind  the  ears,  and  never  except  when  convulsions  or  coma  are  present 
or  threatening,  and  the  patient  is  robust.  The  fact  should  not  be  for- 
gotten that  cerebro-spinal  fever  is  in  its  nature  asthenic  and  protracted, 
and  that  the  intense  inflammatory  congestion  of  the  nervous  centres  can 
ordinarily  be  relieved,  if  relieved  at  all,  by  the  other  measures  recom- 
mended, which  do  not  reduce  the  strength.  The  alarming  symptoms 
which  usher  in  an  attack,  the  intense  headache,  restlessness,  delirium, 
sometimes  eclampsia  or  coma,  seem  to  demand  the  most  energetic  treat- 
ment, and  yet  it  is  surprising  to  one  Avho  has  his  first  experiences  with 
this  malady  how  patients  under  proper  treatment,  without  the  abstrac- 
tion of  blood,  emerge  from  an  aj)parently  almost  hopeless  state  and  ulti- 
mately recover.  There  maybe  total  unconsciousness,  the  pupils  dilated 
like  rings  and  insensible  to  light,  the  head  intensely  hot,  tonic  convul- 
sions present  or  alternating  with  frequent  clonic  convulsions,  and  yet 
these  symptoms,  wliich  in  any  other  disease  would  be  regarded  as  suffi- 
cient to  justify  the  prognosis  of  certain  death,  may  gradually  pass  off 
toward  the  close  of  the  first  or  in  the  second  week,  and  the  case  after- 
ward progress  favorably.  In  the  New  York  epidemic  ot  1872,  pre- 
viously to  which  physicians  of  this  city  had  no  personal  experience  with 
cerebro-spinal  fever,  many  cases  were  pronounced  hopeless  which  ulti- 
aoately  did  well  without  abstraction  of  blood.     In  a  case  occurring  in 

'  ^Medical  and  Physiological  Eegistcr,  1811. 


CURATIVE    TREATMENT  893 

the  practice  of  Dr.  Griswold  the  patient  was  comatose  for  three  days, 
■with  pupils  not  responding,  or  but  very  feebly  responding  to  light,  but 
he  recovered  Avithout  the  abstraction  of  blood,  and  "with  the  remedies 
ordinarily  employed.  In  a  case  which  we  will  presently  relate,  in 
speaking  of  another  local  treatment,  the  patient  was  still  insensible  in  the 
third  week,  with  pupils  greatly  dilated  and  insensible  to  light,  and  yet 
recovered  without  losing  blood.  Such  cases  show  that  the  most  urgent 
symptoms,  such  as  seem  to  indicate  the  prompt  employment  of  leeches 
in  order  to  reduce  the  meningeal  hypera?mia  and  the  consecutive  con- 
gestion of  the  nerve-centres,  may  be  relieved  and  the  patient  recover 
without  such  depletion,  and  with  the  preservation  of  the  blood,  which  is 
so  much  neeiled  in  the  subsequent  asthenic  course  of  the  malady. 

In  oidy  one  case  have  I  recommended  the  abstraction  of  blood,  and 
this  was  so  instructive  that  I  will  briefly  relate  it:  A  girl,  four  years  of 
age,  was  seized  on  March  7,  1873,  Avith  vomiting,  chilliness,  and  tremb- 
ling, followed  by  severe  general  clonic  convulsions  lasting  about  fifteen 
minutes;  was  semi-comatose;  pulse  132,  and  a  few  hours  later,  156; 
temperature  101^°;  respiration  44;  eyes  closed,  pupils  moderately 
dilated  and  feebly  responsive  to  light,  dusky  mottling  of  skin,  constant 
tremulousness  with  tAvitching  of  limbs.  Bromide  of  potassium  Avas  ad- 
ministered in  liourly  doses  of  four  grains,  ice  applied  to  the  head  and 
nucha,  and  a  hot  mustard  footbath  folloAved  by  sinapisms  to  the  nucha. 
On  the  folloAving  day,  March  8th,  she  Avas  partly  conscious,  Avhen 
aroused,  but  inunediately  relapsed  into  sleep,  head  retracted,  boAvels  con- 
stipated; pulse  13G;  temperature  102°;  vomits  occasionally.  It  Avas 
thought  proper,  on  account  of  tlie  extreme  stupor,  to  apply  one  leech  to 
each  temple  and  tlie  bites  trickled  sloAvly  nearly  five  hours.  The  other 
treatment  Avas  continued.  On  the  Uth  the  ])ulse  Avas  180,  so  feeble  that 
it  Avas  counted  Avith  difficulty  ;  temperature  101^^°.  The  patient  was 
evidently  sinking.  It  Avas  necessary  to  order  Avhiskey  in  teaspoonful 
doses  every  two  hours,  Avith  beef-tea  and  other  most  nutritious  drinks. 
Evening,  pulse  172,  still  feeble.  March  10th,  pulse  180,  barely  per- 
ce[»tible;  great  hypenesthesia;  axillary  temperature  100°;  axes  of 
eyes  directed  downward.  After  this  the  patient  gradually  rallied  for  a 
time,  the  pulse  becoming  stronger  and  less  frecpient,  but  death  finally 
occurred  after  nine  weeks  in  a  state  of  extreme  emaciation  and  exhaus- 
tion.    Slight  convulsions  occurred  in  the  last  hours. 

It  is  seen  that  in  the  above  case,  Avhich  may  be  regarded  as  tyjiieal, 
the  patient  passed  into  a  state  of  extreme  prostration  after  the  a])j)lica- 
tiou  of  the  leeches,  so  that  for  three  days  I  did  not  believe  that  she  would 
live  from  hour  to  hour,  and  death  occurred  after  un  illness  of  nine  Aveeks, 
aj)parently  from  sheer  exhaustion.  Experience  like  this,  Avhieh  corre- 
sponds Avith  that  of  most  other  observers,  shoAvs  the  necessity  of  preserv- 
ing the  blood  and  thereby  the  strength,  however  urgent  the  initial  .symp- 
toms, iriasmneh  as  cerebro-spinal  fever  in  its  subseipient  course  is  attended 
by  such  marked  asthenia.  On  May  3,  1S7H,  ji  boy  of  ten  years  Avas 
adniitti'd  into  one  of  our  best  hos[)itals,  in  the  service  of  a  |iroiiiinent 
NcAV  Yoik  ])hysician.  It  Avas stated  that  he  had  been  four  days  sick  with 
cerebro-spinal  fever,  and  among  other  characteristic  symptoms  he  had 
hail  delirium  every  night  and  on  May  2d  delirium  in  the  daytime,  Avhich 


394:  CEKEBRO-SPINAL    FEVER 

had  abated  considerably  after  free  epistaxis.  In  the  hospital  the  appli- 
cation of  ten  leeches  along  the  spine  -was  ordered,  but  it  does  not  appear 
to  have  diminished  the  delirium  or  any  other  symptom,  and  on  the  fol- 
lowing day  the  pulse  was  so  frequent  and  feeble  that  active  stimulation 
by  brandy  was  resorted  to.  He  had  three  strong  convulsions  on  May 
loth,  Avhich  were  relieved  by  ice  to  the  head  and  nape  of  neck,  and  by 
six  minims  of  Magendie's  solution.  Severe  pains  occurred  at  times  in 
the  back  and  limbs,  and  on  the  20th,  one  month  after  the  commence- 
ment of  the  disease,  the  same  pain  frequently  recurring,  twelve  leeches 
were  ordered  to  be  applied  to  the  spine.  On  June  2d  the  limbs  were 
flexed  and  quite  stiff,  and  the  effort  to  move  them  was  attended  by  great 
pain.  The  pain  in  tlie  back  was  also  more  constant,  and  in  consequence 
sixteen  leeches  were  applied  to  the  spine.  The  next  day  there  Avas  no 
pain,  but  the  patient  was  very  stupid.  On  June  Gth  the  records  state 
that  he  was  obviously  losing  strength  day  by  day,  that  his  emaciation 
was  extreme  and  his  ana?mia  very  marked.  But  he  had  great  vitality, 
and  although  he  had  strabismus,  bedsores,  incontinence  of  urine  and 
feces,  and  extreme  jirostration,  he  lingered  till  August  1st.  At  the 
autopsy,  "body,  a  skeleton;  brain,  dura  mater,  and  pia  mater  appear 
normal,  except  a  little  thickening  of  latter  at  base  of  brain;  ventricles 
much  enlarged  and  full  of  clear  serum ;  surface  of  walls  of  ventricles 
looks  normal  but  is  soft;  spinal  cord  and  membranes  appear  normal  to 
the  naked  eye."  No  disease  was  discovered  in  other  organs,  except  that 
the  liver  appeared  congested  and  the  kidneys  pale.  It  can  scarcely  be 
doubted  that,  although  some  temporary  relief  from  the  jiain  may  have 
resulted  to  this  patient  by  the  repeated  application  of  leeches,  which 
diminished  the  meningeal  hypersemia,  yet  his  chances  for  ultimate 
recovery  would  have  been  far  better  without  such  depletion.  Therefore 
the  histories  of  cases  show  that  the  result  of  abstraction  of  blood  has 
been  unsatisfactory,  on  account  of  the  asthenic  nature  and  protracted 
course  of  cerebro-spinal  fever,  and  it  should  be  very  rarely,  if  ever, 
recommended  as  a  remedial  agent. 

Some  benefit  is  apparently  derived  from  the  application  of  stimulating 
and  moderately  irritating  lotions  along  the  spine.  A  liniment  consist- 
ing of  equal  parts  of  camphorated  oil  and  turpentine  briskly  applied  by 
friction  with  flannel  up  and  down  the  spine  till  redness  is  produced, 
appears  to  cause  some  alleviation  of  the  suffering  and  it  does  not  con- 
flict with  the  use  of  the  ice-bag.  Dr.  William  11.  Sutton,  of  Dallas, 
Texas,  has  published  the  folloAving  interesting  case,  showing  the  benefit 
from  stimulating  and  irritant  applications  over  the  spine  made  in  an 
unusual  manner.  A  child,  aged  three  and  one-half  years,  had  been 
thi'cc  weeks  under  treatment,  through  error  of  dingnosis,  for  supposed 
continued  fever.  When  Dr.  Sutton  assumed  charge  of  the  case  on 
November  20,  1877,  the  pupils  Avere  greatly  dilated  and  insensible  to 
light;  features  pallid  and  pinched;  pulse  180;  temperature  103°; 
patient  totally  unconscious.  November  21st,  morning  temperature 
10o°;  pulse  140;  CA-ening  temperature  101 1°;  pulse  120.  Novem- 
ber 22d,  morning  temperature  10(1^°;  pulse  160;  restless;  evening 
tempei-ature  ]05J°;  pulse  120;  had  not  slept  except  for  moments  for 
nearly  two  Aveeks.     A  strip  of  flannel  saturated  Avith  turpentine  Avas 


IXTEEXAL    TEE  ATM  EXT.  395 

placed  over  the  spine  from  the  neck  to  tlie  sacrum,  and  a  hot  smoothing 
iron  was  run  up  and  down  it,  and  eight  drops  of  the  fluid  extract  of 
ergot  were  given  every  three  hours.  Dr.  Sutton  adds:  "The  father 
stated  to  me  that  as  soon  as  the  application  was  finished  the  child  fell 
asleep,  and  slept  several  hours — the  first  for  two  weeks — and  the  fever 
rapidly  declined.  From  this  time  he  bepm  to  improve  and  gradually 
and  fully  recovered.  The  use  of  irritating  applications  over  the  spine 
in  the  treatment  of  cerebro-spinal  fever  has  been  long  and  favorably 
known,  but  the  mode  of  apjilying  it  practised  in  the  above  case  is 
novel. 

IxTERXAL  Treatment. — It  will  aid  in  the  selection  of  the  proper 
remedies  to  recall  to  mind. the  pathological  state  which  we  know  to  be 
present  from  the  many  autopsies  which  have  been  recorded.  We  have 
seen  that  the  largest  mortality,  and  consequently  the  most  dangerous 
period,  is  in  the  first  days,  when  there  is  intense  suddenly  developed 
inflammatory  congestion  of  the  meninges,  with  more  or  less  secondary 
hypeneinia  of  the  underlying  brain  and  spinal  cord,  producing  great 
headache,  delirium,  or  somnolence,  with  exaggerated  reflex  irritability 
of  the  sijinal  cord,  so  that  eclampsia  is  a  common  and  fatal  complication. 

Fortunately  a  remedy  has  been  discovered  in  modern  times,  the 
bromide  of  potassium,  which  acts  promptly  and  efficiently.  It  can  be 
safely  administered  in  large  and  frequent  doses  to  the  youngest  child. 
It  is  quickly  eliminated  from  the  system  through  the  kidneys  and  other 
emunctories  in  children,  so  as  to  prevent  the  occurrence  of  bromism,  at 
least  to  the  extent  of  causing  any  unpleasant  consequences.  It  causes 
contraction  of  the  minute  vessels  of  the  nervous  centres  so  as  to  diminish 
the  hyperoemia,  as  shown  by  the  experiments  and  observations  of  Dr. 
Putnam-Jacobi  and  others,  and  at  the  same  time  it  diminishes,  in  a 
marked  degree,  the  reiiex  irritability  of  the  spinal  cord,  two  most  bene- 
ficial and  iuq)ortant  effects  of  its  use  in  this  disease.  Many  children  by 
its  timely  em])loyment  are  saved  from  the  dangers  of  eclampsia,  and  by 
its  sedative  effect  on  the  nervous  system  and  contraccile  action  on  the 
caj)illarie3  it  probably  diminishes  the  intensity  of  the  inflammation  and 
the  amount  of  exudation.  I  usually  prescribe  it,  as  recommended  by 
Dr.  S(juibb,  dissolved  in  simjde  cold  water.  In  ordinary  cases  not 
attende<l  by  eclampsia  or  marked  symptoms  whiehshow  that  eclampsia 
is  threatening,  I  usually  prescribe  at  my  first  visit  about  four  grains 
every  two  hours  to  a  child  of  two  years,  who  has  the  usual  restlessness 
and  apparent  headache,  and  six  grains  to  a  child  of  five  years.  If 
eclam])sia  occur,  the  bromide  should  be  given  more  fre(picntly,  as  every 
five  or  ten  minutes  till  it  ceases.  It  is  iiiq)f)rtant  to  ])eal)lo  to  (k'tt-niiine 
when  the  (juantity  of  the  bromide  administ(!red  shoultl  be  diminished, 
and  when  its  use  should  be  discontinued.  I  have  very  rarely  observed 
bromism  in  children,  and  never  to  the  extent  of  doing  any  serious  harm, 
though  for  many  years  I  have  administered  it  in  large  and  freipient 
doses  whenever  the  occasion  seemed  to  recpiire  it,  but  the  symptoms  of 
bromism  cannot  readily  be  discriminated  from  those  which  may  result 
from  cerebro-sj)inal  fever,  such  as  muscular  weakness,  dilate<l  pui)ils,  with 
perhajjs  imjiaired  vision,  unsteady  gait,  nausea  or  vomiting,  and  ab- 
dominal pains.     If  the  case  progress  favorably,  frecjuent  and  large  doses 


896  CEREBRO-SriNAL    FEVER. 

should,  in  my  opinion,  be  given  only  in  the  first  week,  after  which  this 
agent  should  be  given  at  longer  intervals,  or  in  smaller  doses.  But 
during  exacerbations,  which  are  liable  to  occur  from  time  to  time  till 
the  patient  is  Avell  on  the  way  to  recovery,  the  use  of  the  bromide  in  full 
doses  is  again  indicated  till  the  urgent  symptoms  begin  to  abate. 

Ergot  is  another  very  important  remedy.  It  is  scarcely  less  useful 
than  the  bromide,  from  its  known  action  in  contracting  the  arterioles 
and  diminishing  the  flow  of  arterial  blood.  The  fluid  extract,  tincture, 
or  wine  of  secale  cornutum  can  be  employed,  or  its  active  principle 
ergotine.  In  this  city  Squibb's  fluid  extract  has  been  more  used  than 
any  other  preparation.  I  have  commonly  presci'ibed  it  except  for 
patients  old  enough  to  take  ergotine  in  the  pill.  The  doses  employed 
by  diff'erent  physicians  vary  greatly,  Dr,  William  A,  Thomson,  Pro- 
fessor of  Materia  Medica  in  the  New  York  University,  has  prescribed, 
so  for  as  I  am  aware,  the  largest  doses  in  the  treatment  of  this  disease, 
to  wit,  one  teaspoonful  of  the  fluid  extract  of  secale  cornutum  every  three 
hours  to  a  boy  of  ten  years  in  Roosevelt  Hospital  in  1878,  with  apparent 
benefit  as  regards  tlie  meningeal  hyperemia,  although  the  case  was  fatal 
after  the  lapse  of  several  months  from  asthenia.  The  alkaloid  ergotine, 
to  which  the  beneficial  effects  of  the  secale  cornutum  are  due,  may  be 
given  in  the  pill  or  in  solution.  In  case  of  much  irritability  of  the 
stomach  it  can  be  employed  hypodermically,  dissolved  in  water  with 
glycerine.  The  efficacy  of  this  agent  is  most  marked  during  the  first 
and  second  weeks,  Avhen  the  congestion  of  the  nervous  centres  is  greatest. 
At  a  more  advanced  stage,  when  there  is  less  congestion  and  the  danger 
arises  from  the  inflammatory  products  and  structural  changes,  the  time 
for  the  use  of  ergot  is  passed,  or  if  it  is  still  of  some  service  it  is  less 
needed  than  at  first  and  should  be  given  less  frequently. 

The  severe  headache  and  restlessness  which  attend  many  cases,  re- 
quire the  occasional  use  of  an  opiate,  or  the  hydrate  of  chloral.  Chloral 
in  proper  dose  never  fails  to  give  quiet  sleej),  and  it  is  supposed  by 
some  Avho  have  studied  its  therapeutic  action  that  it  diminishes  the 
cerebral  circulation.  It  is  therefore  an  useful  adjuvant  to  the  bromide. 
Five  grains  usually  sufl^ice  for  a  child  of  six  to  eight  years.  Chloral  is 
especially  useful  in  cases  attended  by  eclampsia,  or  symptoms  which 
threaten  eclampsia,  since  it  acts  promptly  and  decidedly  in  diminishing 
reflex  irritability.  Formerly  it  was  considered  injudicious  and  unsafe 
to  ])rescribe  opiates  in  meningeal  inflammation,  since  it  was  supposed 
that  they  increased  the  liability  to  coma,  but  experience  shows  that  they 
are  sometimes  very  usefid  in  this  disease  when  administered  in  small  or 
moderate  doses,  and  without  the  risk  Avhich  was  once  supposed  to  be  in- 
curred by  their  use.  The  thirty-second  part  of  a  grain  of  morphia 
administered  at  intervals  of  some  hours  wag  su^cient  to  relieve  the 
suffering  of  one  of  my  patients  at  the  age  of  six  years. 

Quinia  apparently  does  not  exert  any  marked  controlling  effect  on  the 
course  of  cerebro-spinal  fever  or  its  symptoms,  although  the  paroxysmal 
character  of  the  severe  pains  in  many  patients  suggests  the  use  of  this 
agent  as  an  antiperiodic.  It  Avas  frequently  prescribed  by  New  York 
physicians  in  the  epidemic  of  1872,  but  I  believe  that  the  opinion  was 
unanimous  that  it  Avas  not  the  proper  remedy.     I  have  prescribed  it  in 


INTERNAL    TREATMENT.  397 

lar^e  and  small  doses,  in  one  instance  giving  fifteen  grains  to  a  cliild  of 
thirteen  years,  but  do  not  know  that  I  ha\'e  derived  any  benefit  from  its 
use  in  this  malady. 

"When  the  acute  stage  has  abated,  measures  designed  to  remove  the 
serum  Avhich  sometimes  remains,  constituting  a  hydrocephalus,  are  indi- 
cated. For  this  purpose  the  iodide  of  potassium  is  probably  more  useful 
than  any  other  agent.  It  is  administered  by  some  physicians  early, 
along  with  the  bromide,  as  they  have  been  in  the  habit  of  treating  other 
forms  of  meningitis.  I  have  prescribed  it  with  the  bromide,  and  alone 
when  the  bromide  was  discontinued,  but  Avhether  it  produces  a  sorbe- 
facient  effect  in  this  disease  seems  to  me  doubtful. 

The  result  depends  to  a  great  extent  on  the  nursing.  The  skill  of 
the  physician  may  be  thwarted  and  the  life  of  the  patient  lost  by  in- 
efficient nursing.  No  other  disease  more  urgently  requn-es  kind,  intelli- 
gent, and  constant  attendance  niglit  and  day  on  the  part  of  the  nurses. 
Not  only  should  the  medicines  and  nutriment  be  given  punctually  and 
regularly,  but  the  great  restlessness  of  the  patient  in  the  first  days 
requires  constant  readjusting  of  the  ice-bags,  and  during  the  long  period 
of  convalescence  the  utmost  care  is  recjuired  to  remove  at  once  the  excre- 
tions in  order  to  prevent  bedsores,  and  to  give  the  proper  amount  and 
kind  of  nutriment  to  prevent  the  emaciation  and  weakness  from  which 
many  perish.  Among  my  cases  are  those  who  owed  their  recovery  largely 
to  the  untirinix  devotion  of  mothers.  The  one  that  died  of  bedsores  I 
have  little  doubt  would  have  recovered  had  the  nursing  been  such  as 
some  of  the  others  received. 

The  diet,  from  the  beginning  to  the  end  of  the  raalad}'-,  should  be  the 
most  nutritious,  and  such  as  is  easily  digested.  It  is  necessary  to  give 
it  in  the  liquid  form,  unless  in  mild  cases  in  Avhich  the  appetite  may  not 
be  entirely  lost.  It  is  proper  to  aid  the  digestion  by  pepsine  prepara- 
tions. Nutritive  enemata,  consisting  of  beef-tea,  or  Leube's  extract  of 
beef,  milk,  and  brandy,  aid  in  averting  the  fatal  prostration  in  protracted 
cases.  After  the  acute  stage  has  passc<l  by  and  the  meningeal  hyper- 
aemia  has  abated,  the  alcoholic  compounds  in  moderate  doses,  which  in 
the  beginning  would  be  very  injurious,  may  now  be  useful,  administered 
regidarly  by  the  mouth.  The  room  should  be  dark,  well  ventilated, 
and  quiet.  All  sympathizing  friends  who  are  not  required  in  tlie  nurs- 
ing should  be  excluded.  I  know  no  other  disease  in  which  this  is  so 
necessary,  for  mental  excitement  may  produce  dangerous  aggravation 
of  symptoms.  Recently  a  young  lady,  to  whom  I  made  one  visit  in 
constdtation,  and  whose  recovery  seemed  probable,  was  allowed  to  receive 
the  visit  of  a  young  gentleman.  Immediately  after  his  departure  her 
headache  was  intensified,  the  symptoms  became  generally  aggravated, 
and  the  result  in  a  few  days  was  fatal. 


398  ACUTE    RHEUMATISM 


CHAPTER    Y. 

ACUTE  EHEUMATISM. 

Rheumatism  is  a  constitutional  disease  with  a  local  manifestation, 
to  wit,  inflammation  of  the  sero-fibrous  tissues,  chiefly  in  and  around 
the  articulations,  but  occasionally  in  the  heart.  It  was  formerly  sup- 
posed to  be  rare  in  children,  but  more  accurate  observations  show  that 
it  is  scarcely  less  common  during  childhood  than  in  adult  life.  In  young 
patients,  especially  under  the  age  of  six  or  eight  years,  it  is  frequently 
overlooked,  for  the  articular  inflammations  in  such  patients  are  com- 
monly slight.  In  the  last  fifteen  years,  during  my  connection  with  the 
children's  class  in  the  Bureau  for  the  Relief  of  the  Outdoor  Poor,  I  have 
examined  many  children  Avith  rheumatism  or  the  cardiac  lesions  result- 
ing from  rheumatism,  and  ordinarily  I  have  found  that  few  joints  were 
affected,  and  that  there  had  been  but  little  swelling  of  them,  or  redness, 
and  that  the  patients  were  almost  never  confined  to  bed,  or  even  to  the 
sitting  posture,  but  had  been  able  to  walk  about,  though  with  restraint 
and  complaint  of  pain  or  soreness.  The  parents  in  many  instances  sup- 
posed that  their  children  were  suff"ering  froui  "growing  pains,"  as  they 
designated  them.  At  the  same  time,  with  this  mildness  of  symptoms, 
the  heart  was  becoming  seriously  and  permanently  crippled,  by  endo- 
carditis. Those  who  have  attended  my  clinics  will  recollect  that  on 
some  days  as  many  as  three  or  four  children  with  cardiac  lesions  have 
been  present  whose  histories  showed  an  overlooked  rheumatism  of  this 
mild  type.  Cases  like  the  following  are  very  common  among  the  city 
poor: 

In  January,  1871,  a  little  girl,  three  years  old,  was  presented,  having 
distinct  aortic  direct,  and  mitral  regurgitant  murmurs.  The  mother 
was  not  aware  that  she  had  had  rheumatism,  but  at  the  age  of  twenty 
months  she  had  for  several  days  pretty  active  febrile  symptoms,  which 
the  physician  attributed  to  some  other  ailment.  In  April,  1871,  another 
girl,  of  the  same  age,  was  brought  to  the  clinic,  having  a  distinct  mitral 
regurgitant  murmur.  The  mother  stated  tliat  she  had  been  well  till  a 
month  previously,  when  she  was  confined  to  her  bed  for  a  few  days, 
having  a  high  fever.  She  was  attended  by  a  homoeopathic  physician, 
and  the  exact  character  of  her  sickness  the  mother  was  not  able  to  state. 
Further  medical  advice  Avas  sought,  as  the  child  remained  delicate,  though 
her  health  was  better  than  at  first.  There  can  be  little  doubt  that  the 
obscure  fever  in  this  case  was  rheumatic.  In  another  child  treated 
elsewhere,  not  old  enough  to  relate  the  subjective  symptoms,  there  was, 
in  addition  to  an  intense  fever,  evident  pain  in  one  foot  or  leg,  when  the 
limb  was  moved.  Still,  the  nature  of  the  disease  was  not  diagnosticated 
till  some  time  after  recovery,  when  a  valvular  murmur  was  accidentally 
discovered.     Such  histories,  Avhich  are  not  rare   show  that  rheumatism 


SYMPTOMS.  399 

often  occurs  in  young  children,  even  infants,  and  they  inculcate  the 
important  practical  lesson,  that  the  disease  at  this  age  may  be  so  ob- 
scure, or  latent,  as  to  be  overlooked  even  by  good  diagnosticians. 

Some  observers,  meeting  cases  of  valvular  disease  in  children,  without 
the  history  of  rheumatism,  have  concluded  that  rheumatism  is  not  the 
chief  cause  of  endocarditis  at  this  age  ;^  but  the  explanation  Avhich  I 
have  given  seems  to  me  more  in  consonance  with  the  facts.  Scarlet 
fever  not  infrequently  causes  endocarditis,  but  this  exanthem  seldom 
occurs  without  detection,  and  it  has  been  as  often  absent  as  has  rheu- 
matism from  the  histories  as  given  by  the  parents  of  young  children 
Avith  valvular  disease,  Avhom  I  have  examined.  Moreover,  the  endo- 
carditis of  scarlet  fever  is  in  many  cases  associated  with,  if  it  do  not 
result  from,  scarlatinous  rheumatism. 

Rheumatism  in  children  is  primary  or  secondary.  The  secondary 
form  occurs  chiefly  in  the  declining  stage  of  scarlet  fever  and  variola. 
It  is  stated,  also,  to  occur  occasionally  in  newborn  inflmts  during  epi- 
demics of  puerperal  fever,  but  I  have  not  observed  such  cases. 

Causes. — An  inherited  rheumatic  diathesis  is  universally  recognized 
as  an  important  predisposing  cause  of  this  disease,  so  that  it  frequently 
occurs  in  different  members  of  the  same  family.  When  the  family 
history  shows  a  strong  predisposition  to  rheumatism,  it  occurs  in  the 
child  from  a  slight  exciting  cause;  if  no  such  predisposition  exist,  it 
only  occurs  through  unusual  circumstances  of  exposure.  The  ordinary 
exciting  cause  is  the  same  as  in  most  idiopathic  inflammations,  to  wit, 
exposure  to  cold ;  but  a  strong  rheumatic  diathesis  appears  to  be  suffi- 
cient in  itself  to  produce  an  outbreak  of  the  disease.  Children  Avho 
have  had  one  attack  are  especially  liable  to  another. 

The  morbific  principle  in  the  blood  which  produces  the  phenomena 
and  lesions  of  rheumatism,  is  supposed  to  be  lactic  acid,  a  theory  which 
originated  Avitli  Prout,  and  is  strengthened  rather  than  weakened  by 
observations  since  his  day.  According  to  this  theory,  lactic  acid  sustains 
the  same  causative  relation  to  acute  rheumatism  as  uric  acid  to  gout,  and, 
as  Prof  Austin  Flint  states,  it  receives  support  from  the  fact  that  the 
lactic  acid  treatment  of  diabetes  may  produce  rheumatic  inflammation 
of  the  joints. 

Symptoms. — The  commencement  of  acute  idiopathic  rheumatism  is 
in  most  cases  sudden ;  occasionally  fever,  and  a  degree  of  soreness  or 
8ti(1Vie3->,  precede  the  articular  aft'ectiou  for  a  few  hours  or  days.  The 
inflammation,  slight  at  first,  increases  craduallv,  attaining  its  maximum 
intcn-^ity  within  one  or  two  days.  The  joint  is  painful,  red,  hot,  and 
swollen.  The  swelling  is  due  to  inflammatory  oedema  of  the  tissues 
surrounding  the  joint  and  eflusion  within  the  joint.  As  in  all  inflam- 
mations, tiie  vascularity  of  the  parts  involved  is  increased,  the  synovial 
membrane  loses,  more  or  less,  its  lustre,  and  the  eflused  fluid,  which  is 
mainly  serum,  has  been  found,  in  most  of  the  cases  in  which  an  oppor- 
tunity was  presented  to  examine  it,  to  contain,  like  the  ])leuritic  exu<la- 
tion,  a  few  globules  of  pus.  Rarely,  in  a  reduced  state  of  the  system, 
so  much  |)us  is  jM'oduced  within  the  joint  as  to  constitute  a  true  abscess, 
and  rarely  also  fibrin  is  exuded,  producing  a  rubbing  sensation  when 

'  Dr.  A.  Steffen,  Jahrbuch  fur  Kinderh.,  1870. 


•iOO  ACUTE    RHEUMATISM. 

the  joint  is  moved,  and  endangering  permanent  adhesion  of  the  articular 
surfaces.  Fortunately,  however,  in  the  vast  majority  of  cases,  the  sub- 
stance exuded  both  without  and  ■within  the  joint  is  mainly  serum,  and 
hence  the  rapid  subsidence  of  the  swelling  when  the  inflammation  ceases. 
The  pain  is  commonly  not  severe  when  the  child  is  quiet,  but  it  is 
greatly  increased  if  the  joint  be  pressed  or  the  limb  moved. 

The  joints  of  the  extremities  are  most  frequently  the  seat  of  rheu- 
matic inflammation,  but  occasionallj  those  of  the  trunk,  as  the  inter- 
vertebral, the  symphysis  pubis,  etc.,  are  involved.  As  the  inflammation 
abates  in  the  articulations  first  affected,  it  reappeai's  in  others,  unless 
the  materies  morbi  have  been  eliminated  from  the  system.  It  is  seldom 
that  more  than  two  or  three  of  the  joints  are  in  a  state  of  active  inflam- 
mation at  the  same  time. 

The  temperature  in  acute  rheumatism  is  elevated  two  or  three  degrees 
above  that  of  health,  and  the  pulse  varies  from  120  to  140,  its  frequency 
depending  on  the  age  of  the  patient,  as  well  as  the  gravity  of  the  dis- 
ease. Perspiration  is  a  common  symptom.  The  appetite  is  impaired, 
the  tongue  slightly  coated,  and  the  bowels  constipated.  The  watery 
element  in  the  urine  is  diminished,  as  in  most  febrile  diseases,  and  there 
is  not  a  corresponding  reduction  in  the  solid  elements,  so  that  the  urine 
is  rendered  more  dense,  and  its  specific  gravity  is  high.  The  amount  of 
urea  and  coloring  matter  excreted  from  the  kidneys  is  augmented  during 
the  active  period  of  rheumatism,  and  the  urine,  when  it  cools,  deposits 
urates.  In  ordinary  cases  there  is  no  prominent  symptom  referable  to 
the  nervous  system,  with  the  exception  of  pain  in  the  affected  joint. 

Acute  rheumatism,  if  only  the  articidations  were  involved,  would  be 
a  disease  of  little  danger,  however  painful,  but  unfortunately  in  its 
proneness  to  produce  specific  inflammation  of  the  sero-fibrous  tissues,  the 
heart  frequently  becomes  involved,  less  frequently  the  lungs  and  pleura, 
and  in  rare  instances  the  cerebral  or  spinal  meninges.  Endocarditis  is 
the  most  frequent  of  the  heart  inflammations  occurring  in  rheumatism; 
pericarditis,  though  less  common,  is  not  infrequent,  while  in  rare  in- 
stances myocarditis  occurs,  usually  associated  with  the  other  inflamma- 
tions. Endocarditis  is  limited  to  the  left  side  of  the  heart,  and  seldom 
continues  long  without  engaging  the  valves,  aortic  or  mitral,  or  both, 
causing  their  infiltration,  fibroid  degeneration,  with  consequent  thick- 
ening, and  sometimes  adhesion.  The  valvular  lesion  thus  produced  is 
in  most  instances  permanent,  so  impairing  tiie  action  of  the  valves  as 
to  obstruct  in  greater  or  less  degree  the  flow  of  blood  through  the  orifice 
and  allow  its  regurgitation. 

The  mitral  valve  is  more  frequently  affected  than  the  aortic,  at  least 
bruits  produced  by  this  lesion  are  more  frequent  in  the  mitral  than 
aortic  orifice,  and  when  they  are  heard  in  both  orifices  they  are  commonly 
loudest  in  the  mitral.  This  fact,  noticed  by  different  observers,  I  have 
repeatedly  verified  by  observations  in  this  city. 

While  the  articular  affections  pertain  to  the  clinical  history  of  I'heu- 
matism,  the  internal  inflammation,  whether  of  the  heart,  lungs,  pleura, 
or  meninges,  though  similar  as  regards  its  pathological  character,  is 
properly  considered  as  a  complication.  Acute  rheumatism  is  so  fre- 
quently complicated  by  one  or  the  other  of  these  affections,  that   any 


PROGXOSIS. 


•40] 


Fig.  26. 


disproportionate  severity  in  the  general  symptoms,  as  compared  ■with 
the  inflammation  of  the  joints,  or  any  sudden  and  unexpected  increase 
in  the  symptoms,  should  always  lead  the  physician  to  examine  thor- 
oughly the  condition  of  those  organs  which  are  most  frequently  affected. 

Inilammatory  complications  occur,  as  a  rule,  during  the  active  period 
of  rheumatism,  when  the  inllammation  is  passing  from  joint  to  joint. 
If  the  general  symptoms  begin  to  improve,  and  no  new  joints  ai-e  in- 
volved, the  liability  to  complications  is  greatly  diminished.  Secondary 
rheumatism,  occurring  in  most  instances  in  connection  with  certain 
eruptive  fevers,  especially  scarlatina,  commonly  affects  only  a  few  joints, 
often  only  one  or  two,  as  the  wrist,  and,  though  painful,  is  attended 
by  sliglit  swelling  and  redness. 

Duration — Progxosis. — With  proper  treatment  and  Avithout  com- 
plication the  febrile  action  in  a  few  days  begins  to  abate,  and  the  dis- 
ease commonly  terminates  within  two  weeks  Its  duration  is  ordinarily 
shorter  than  in  rheumatism  of  the  adult.  Fluctuations,  however,  are 
liable  to  occur.  The  disease  may  appear  to  be  abating,  and  the  articular 
inflammations  nearly  cease,  when  they  return  for  a  time,  often  without 
new  exposure  and  without  appreciable  cause.  The  prognosis,  even  when 
cardiac  inflammation  has  supervened,  is  in  most  cases  favorable,  except 
so  far  as  the  lesion  resultins  from  this  inflammation  is  concerned,  which 
being  permanent  may  entail  much  subsequent  suffering,  and  occasion 
death  after  months  or  years.  Indeed,  what  is  most  to  be  dreaded  in 
cases  of  acute  rlieumatism  is  valvular  disease  or 
pericardial  adhesion  with  its  remoter  consequences, 
namely,  hypertrophy  of  heart,  congestion  and 
oedema  of  lungs,  dropsies,  etc. 

Secondary  rheumatism  occurring  in  scarlet  fever 
is  sometimes  also  complicated  with  or,  ratlier  coex- 
ists with,  cardiac  inflammation,  pleuritis,  or  pneu- 
monitis, rendering  the  prognosis  more  unfavorable. 

In  rare  instances  the  acute  symptoms  of  rheu- 
matism abate,  but  the  joints  remain  stifi' and  more 
or  less  swollen,  and  painful  when  moved.  The 
acute  has  lapsed  into  a  subacute  or  chronic  rheu- 
matism. Such  a  case,  represented  in  the  accom- 
panying figure,  was  brought  to  the  children's  class 
in  the  Outdoor  Department  at  Bellevue  Hospital, 
in  Fcl)ruary,  1S71.  E.  II.,  a  female,  3^  years 
old,  had  intermittent  fever  from  the  age  of  nine 
to  fifteen  months.  From  this  time  she  remnincd 
well  till  the  ago  of  two  years,  when  she  was  taken 
with  acute  rheumatism,  commencino;  in  her  ankles 
and  extending  to  other  joints.  The  knee  and  hip 
joints  on  bolh  sides  have  only  ])artially  recovered 
their  m()l)ility,  and  both  legs  and  both  thighs  are 
permanently  flexed,  so  that  the  gait  is  slow  and  unsteadv.  It  is  iiu- 
possible  to  straighten  either  limb  without  causing  great  pain,  iind 
attempts  to  straighten  the  thigh  j)roducc  the  arch  in  the  back  very 
similar  to  that  in  coxal-^ia. 

26 


402  ACUTE    KHEUMATISM. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases,  if  a  proper  exam- 
ination be  made.  In  the  commencement,  it"  the  aftection  of  the  joints 
be  slight,  rheumatism  might  be  mistaken  for  remittent,  typhoid,  one  of 
the  eruptive  fevers,  or  meningitis  ;  but,  on  careful  examination,  tender- 
ness of  one  or  more  of  the  articulations  will  be  observed,  and  probably 
some  swelling.  This  tenderness  is  readily  distinguished  from  the  hyper- 
sesthesia  Avhich  is  common  in  the  first  stage  of  the  essential  fevers,  and 
which  is  observed  when  pressure  is  made  upon  the  chest  or  abdomen  as 
well  as  upon  the  limbs,  and  is  more  marked  between  the  joints  than  in 
them.  Any  doubt  which  may  at  first  exist,  whether  the  patient  may 
not  have  one  of  those  diseases,  is  soon  dispelled,  since  their  clinical 
history  presents  notable  differences  from  that  of  rheumatism. 

I  have  known  scrofulous  arthritis,  or  scrofulous  ostitis  near  the  joint, 
present  so  close  a  resemblance  to  acute  rheumatism  as  to  be  at  first 
mistaken  for  it.  In  one  instance  this  inflammation  commenced  nearly 
simultaneously  in  three  joints,  rendering  the  diagnosis  at  first  very  diffi- 
cult. But  scrofulous  inflammation,  as  well  as  that  from  pyiemia,  can  be 
diagnosticated  from  rheumatic  disease  of  the  joints,  by  its  greater  per- 
sistence, less  induration  and  symmetry  in  the  swelling,  and  by  the  his- 
tory of  the  case.  Chronic  rheumatism  may  produce  deformity  similar 
to  that  from  chronic  scrofulous  inflammation,  as  in  the  case  mentioned 
above,  but  the  rheumatic  history,  number  of  joints  affected,  bilateral 
character  of  the  inflammation,  good  general  health,  etc.,  are  sufficient  to 
establish  a  clear  diagnosis,  Avhen  the  disease  has  been  observed  for  some 
days. 

Treatment. — The  theory  of  the  pathology  of  a  disease  determines 
the  mode  of  treatment,  and  the  theory  that  rheumatism  is  due  to  an  acid 
in  the  blood,  probably  lactic,  though  not  established,  has  been  widely 
received,  and  has  led  to  the  extensive  employment  of  alkalies,  as  tartrate 
of  sodium  and  potassium,  acetate  of  potassium,  etc.  The  alkaline  treat- 
ment apparently  materially  abridges  the  duration  of  acute  rheumatism  ; 
but  lately  a  new  remedy,  namely,  salicylic  acid,  has  been  found  to  act 
almost  as  a  specific  in  a  large  proportion  of  cases,  quickly  relieving  the 
pain,  and  subduing  the  inflammation,  so  that  a  few  days  suffice  to  effect 
a  cure.  Speedy  cure  of  this  malady  is  urgently  demanded,  on  account 
of  the  imminent  peril  to  the  heart.  Children  are  very  liable  to  the 
cardiac  comjflication.  Although  salicylic  acid  frequently  causes  the  dis- 
appearance of  all  symptoms  within  a  week,  they  are  apt  to  reappear 
unless  the  medicine  be  continued  in  occasional  doses  for  some  days  sub- 
sequently, as  I  have  had  opportunity  to  observe.  It  should  be  prescribed 
with  an  alkali,  as  in  the  following  formula,  which  is  similar  to  one  em- 
ployed in  the  Outdoor  Department  at  Bellevue : 

B. — Acid,  salicylic.      ......     _:;ij-iij. 

Potas.  acetat.         ......     _^s-:. 

GlyccriniB     .         .         .         .  .         •      ^j- 

Aqupe    .         .         .         .         .         .         .         .     q.  s.  ad  5  v. — Misce. 

Give  one  teasj)oonful  every  three  liours  to  a  child  of  six  years. 

A  new  remedy,  producing  useful  therapeutic  effects,  is  apt  to  be  pre- 
scribed at  first  for  too  many  distinct  pathological  states,  till  finally  its 
use  is  restricted  to  such  conditions  as  it  is  found  to  relieve.      Salicvlic 


TREATMENT.  403 

acid  has  undergone  this  trial,  and,  while  it  has  been  rejected  as  a  remedy 
for  the  infectious  diseases,  it  is  recognized  as  the  most  useful  of  all 
remedies  for  the  disease  which  we  are  now  considering.  An  occasional 
opiate,  as  Dover's  powder,  may  also  be  needed  between  the  doses  of  the 
acid. 

An  eligible  mode  of  prescribing  salicylic  acid  is  in  the  salicylate  of 
sodium,  which  is  very  soluble  and  not  so  unpleasant  to  the  taste  as 
salicylic  acid  in  combination  with  most  other  bases.  It  is  used  more 
than  any  other  preparation  of  salicylic  acid  in  New  York,  and  much 
more  than  any  other  remedy  for  the  treatment  of  acute  rheumatism,  and 
ordinarily  with  a  good  result.  It  may  be  administered  in  a  formula 
like  the  following : 

K. — Sodii  salicylat.  ........      ^ij. 

Syr.  bill,  tulut. 5ij. 

Aqufe 5vj. 

Dose,  a  dessertspoonful  every  two  or  three  hours  to  a  child  of  five  years. 

Recently  I  employ  the  followinji  formula,  since  the  oil  of  wintersrreen 
contains  a  considerable  amount  of  salic3'lic  acid  : 

li.--OI.  gaultheriaj     .......      ^j. 

Sodii  Siilicylat.      .         .         .         .         .         .         .      ^nj. 

Syr.  simpliu.         .......      5ii.i- 

Aqiiie  ........      3vj. — Misce. 

Dose,  a  dessertspoonful  to  a  child  of  five  years. 

During  the  declining  period  of  rheumatism  and  in  convalescence  qui- 
nine or  some  preparation  of  cinchona  should  be  employed  and  the  above 
•  medicine  given  less  often.  This  tonic  does  indeed  appear  to  exert  a 
beneficial  effect  on  the  course  of  rheumatism,  and  it  is  employed  by 
some  judicious  and  experienced  physicians  from  the  commencement. 

If  there  be  a  high  temperature  and  a  quick  pulse,  quinine  adminis- 
tered in  an  occasional  large  dose  will  be  found  very  useful.  Three  to 
five  grains  may  be  given  to  a  child  of  five  years. 

Rheumati.sui  impoverishes  the  blood,  and  the  patient  often  begins 
to  present  an  anremic  appearance,  when  he  requires  iron  in  addition 
to  the  vegetable  tonic.  The  citrate  of  iron  and  quinine  may  then  be 
employed. 

Secondary  rheumatism  requires  sustaining  treatment  from  the  first. 
Such  cases  ordinarily  do  well  without  anti-rheumatic  treatment,  with 
the  general  supporting  jneasures  employed  for  the  primary  disease. 

Pneumonitis  com|>licating  rheumatism  is  best  treated  by  moderate 
counter-irritation  and  emollient  poultices,  and  tlie  internal  use  of  car- 
bonate of  ammonium  or  quinine.  In  pericarditis  or  endocarditis,  if,  as 
is  commonly  the  case,  the  movements  of  the  heart  be  accelerated,  aconite 
or  the  tincture  or  infusion  of  digitalis,  is  demanded  to  the  extent  of  I'e- 
diicing  the  number  of  pulsations  to  near  the  normal  frequency.  A 
child  of  six  years  can  take  three  drops  of  the  tincture  or  a  large  tea- 
spoonful  of  the  infusion,  to  be  repeated,  if  necessary,  in  three  hours, 
till  the  re(juired  reduction  of  the  pulse  is  effected.  Patients  often 
experience  relief,  by  tlie  use  of  tliis  agent,  from  the  pal|)itation  ami 
dyspnoea  consequent  upon  the  embarrassed  movements  of  the  heart. 
If  the  heart  disease  be  severe  and  pulse  feeble,  quinine  is  also  useful. 


404  ERYSIPELAS. 

The  patient  shouW  be  kept  (piiet,  in  a  room  of  uniform  temperature, 
and  not  exposed  to  draughts  of  air.  Bj  such  precautions  the  danger 
of  complications  is  greatly  diminished.  Repellant  applications,  as  cold 
or  irritants,  should  not  be  applied  to  the  joints,  so  long  as  the  disease  is 
acute,  for  they  also  increase  the  danger  of  complications.  The  affected 
joints  should  be  enveloped  in  flannel  or  cotton,  and  the  pain,  if  intense, 
may  l)e  diminished  by  applying  flannel  wrung  out  of  warm  water.  If 
the  disease  become  subacute  or  chronic,  if  the  urates  have  disappeared 
from  the  urine,  and  the  inflammation  cease  to  pass  from  joint  to  joint, 
the  tincture  of  iodine,  or  moderately  stimulating  embrocations,  applied 
to  the  joints,  involve  no  danger  and  are  useful. 


CHAPTER  YI. 


ERYSIPELAS. 


The  term  erysipelas  is  applied  to  a  constitutional  or  blood  disease, 
which  is  characterized  by  inflannnation  of  the  skin  and  subcutaneous 
connective  tissue,  and  by  a  tendency  to  spread.  It  is  accompanied  by 
pungent  and  pricking  heat,  swelling,  and  subcutaneous  infiltration. 

In  rare  instances,  in  young  infants,  an  inflammation  which  has  been 
designated  erysipelas  occurs  in  and  around  the  umbilicus.  It  com- 
mences about  the  time  of  the  detachment  of  the  umbilical  cord,  and  is  ac- 
companied by  redness  of  the  skin  and  tumefaction,  with  induration  of  the 
connective  tissue  surrounding  the  umbilicus.  It  usually  causes  ulcera- 
tion of  the  umbilical  fossa,  and,  in  fatal  cases,  pus  is  sometimes  found 
in  the  umbilical  vessels.  This  disease  does  not  show  any  tendency  to 
spread;  the  diameter  of  the  inflamed  surface  is  not  more  than  three  or 
four  inches,  with  the  umbilicus  at  the  centre.  It  is  generally  fatal ; 
but  two  favorable  cases  have  been  reported  to  me,  in  one  of  which  there 
was  considerable  ulceration,  and  after  recovery  a  firm  cicatrix  occupied 
the  site  of  the  umbilicus.  The  most  reasonable  view  is  that  this  disease 
is  primarily  an  inflammation  of  the  umbilical  fossa  and  vessels,  induced 
by  uncleanliness,  cachexia,  or  other  cause.  It  lacks  the  distinguishing 
feature  of  erysipelatous  inflammations,  namely,  the  tendency  to  spread, 
and  I  shall,  therefore,  take  no  further  notice  of  it  in  this  connection. 
(See  Diseases  of  the  Umbilicus.) 

Erysipelas  occasionally  occurs  in  childhood  ;  the  cases  which  are  met 
in  this  period  present  nearly  the  same  features,  and  pui'sue  nearly  the 
same  course,  as  in  the  adult.  In  infancy,  erysipelas  is  a  common  dis- 
ease, and  the  following  remarks  relate  chiefly  to  erysipelas  occurring 
in  this  period  of  life.  They  are  based  on  data  derived  mainly  from  the 
records  of  cases  which  occurred  in  this  city,  some  in  my  own  practice, 


ERYSIPELAS. 


-iOo 


and  others  in  the  practice  of  physicians  known  to  be  good  observers. 
The  points  of  chief  interest  in  forty-one  cases  are  embraced  in  the 
following  table  : 

Cases  of  Infantile  Erysipelas. 


Age. 

Point  of 

PaUTS  AliECTKD 

DUR.^TIO.S 

Result. 

o 
!5 

•A 

■r. 

C'l.nJIEXCEME.XT 

1 

M. 

J  months. 

Right  knee. 

Entire  surface,  except  face  and  scalp       5  weelcs  and 

3  days. 

Recovered. 

2 

M. 

2  years. 

Left  knee. 

From  a  little  above  the  knee  to  the    7  days, 
aukle. 

Recovered. 

3 

M. 

10  months. 

Elbow. 

Whole  arm  an(\  forearm.                            

Recovered. 

4 

F. 

2D  muutbs. 

Below  right  knee 

Entire    leg,  thigh,   and  trunk   to  the|   7  days, 
'umbilicus                                               | 

Recovered. 

6 

F. 

0  months 

Vulva. 

-Vbdomen,  chest,  and  all  the  extremi-  18  daj's. 

ties                                                          \ 
Both  lower  extremities,  abdomen  to'  G  days. 

Recovered. 

6 

M.  ' 

9  days. 

Genitals. 

Died; 

the  umbilicus. 

7 

F 

I  year. 

Vulva. 

Entire  surface,  except  face. 

6  weeks 

Recovered. 

8 

F-   1 

li  weeks. 

At  or  near  the 

ear 

Forehead  and  side  of  face. 

1  week. 

Died  in  tefcinic 
sjiasms 

9 

•• 

9  months. 

Epigastric  region 

Trunk  and  lower  extremities.     '             2  weeks. 

Died  in  tetiinic 
spasms. 

10 

F. 

10  months 

At  an.?Ie  of 
mouth. 

Entire  face  and  scalp.                               10  days. 

Recovered. 

11 

F. 

4  weeks. 

Vulva. 

Entire  surface,  except  face.                    1  3  weeks. 

Died. 

12 

F. 

3  moiitlis. 

Vulva. 

Surface  of  abdomen  to  umbilicus  and 
right  lower  extremity. 

2  weeks. 

Recovered. 

13 

F. 

4  to  5  mos. 

Vulva. 

.\ll  the  limbs  and  trunk,  except  the 
chest. 

3  to  4  weeks 

Died. 

14 

F. 

5  months. 

From    syphilitic 
sores      around 
anus. 

Trunk  and  both  lower  extremities. 

15 

F. 

3  months. 

Vulva. 

Entire    trunk    and    both    upper    ex- 
tremities. 

3  weeks. 

Recovered. 

IC 

M. 

8  months. 

Face    near    nos- 
trils 

Entire    trunk    and    both    upper    ex- 
tremities 

About  2 
weeks. 

Recovered. 

17 

F 

4  months. 

Vulva. 

Entire  trunk  and  all  the  extremities. 

1  week 

Died. 

18 

F. 

7  months 

Knee. 

A  portion  of  trunk  and  both  lower  ex- 
tremities. 

3  woela. 

Recovered. 

19 

F. 

G  months. 

Near  the  tsar. 

Entire  f:ici>  and  forehead. 

10  days. 

Recovered. 

20 

M. 

7  .lays. 

Left  eyelid 

Left  side  of  face. 

3  days 

Died. 

21 

Bl 

14  (lays 

Ueuitiils 

Exteniled   to  knee,  over  abdomen  to 
the  chest 

4  days. 

Died. 

22 

M 

3  mouths 

Under  the  chin. 

Chin,   left  cheek,   nock,   left    side  of 
trunk,  left  thigh  and  leg                      ! 

23 

F 

28  months 

Right  shoulder. 

Arm  and  forearm.                                       1  day. 

Died    in    con- 

vulsions. 

24 

F 

3  or  4  (lays. 

Vulva. 

Body  and  all  the  limbs. 

12  days. 

Died. 

20 

F. 

3^  uios.    • 

Under  left  ear. 

Neck,  chest,  and  arms. 

About  2 
weeks. 

Died. 

2G 

•• 

7  months 

Below  right  knoe 

Trunk,  neck,  and  he^id,  and  all  the    2  weelcs 
limbs. 

Died  comat(jso. 

27 

F 

n  months 

Vulva 

Both  thighs,  and  nearly  entire  trunk.    3  days. 

Died  comatose. 

28 

M 

19  months. 

Near  point  of 

Shoulder,  arm,  and  forearm                     21  days. 

Recovered. 

vaccination. 

29 

M. 

4  mouths. 

Near  jwiint  of 
vaccination. 

Chest,  and  both  upper  limbs 

2  weeks. 

Recovered. 

80 

F. 

2  months. 

Near  vjiccino 
vesicle. 

Trunk,  and  all  the  limlis 

10  days 

Died. 

31 

3  to  4  mos. 

Near  vaccino 
vesicle. 

Arm,   forearm,  and  shoulder  on   one 
side 

2  to  3  weeks 

Died. 

32 

F. 

4  months. 

Near  vaccino 
vesicle 

Arm,  forearm,  and  trunk. 

2  months. 

Died. 

33 

M. 

2  months. 

Near  vaccine 
v<.tilclo 

Nearly  entire  surface. 

1  week 

Died  with 
peritonitis. 

34 

M. 

5)/^  mos. 

Near  |H)int  of 
vaccliiallon 

Arm  and  forearm. 

Recovered. 

86 

M. 

2J^  mos. 

N(.'ar  point  of 
vaccination. 

.\rm. 

7  days. 

Died  prolialil.T 
of  peritonitis 

3G 

M. 

8  mimths 

Near  vaccina 
vesicle. 

.\rm  and  forearm. 

17  days 

Died. 

37 

5  months. 

U-ft  foot. 

Leg,  thigh,  anil  lower  part  of  trunk.   '  2  weeks 

Pled  with 

piK-umoniti!: 

38 

ft  W('<>kB. 

At  one  ear. 

Entire  surface 

2  weeks. 

Recovered 

89 

2  tiiontlis 

L<(rt  loK. 

Trunk,  and  all  fh(>  limbs. 

2  weeks. 

Recovered. 

40 

4  niontlia. 

Near  |M)int  of 
vaccination 

Trunk,  and  all  the  limbs. 

2  weeks. 

Died. 

41 

M. 

14  months. 

Face. 

Trunk,  and  all  the  limbs 

4  weeks 

Rocovorod. 

406  ERYSIPELAS. 

Age. — Of  the  above  cases,  27  were  under  the  age  of  six  months ;  9 
from  six  months  to  twelve,  and  only  5  above  the  latter  age.  A  large 
majority,  therefore,  of  cases  of  infantile  erysipelas  occur  in  the  first 
year  of  life. 

PoixT  OF  Commencement. — In  58  cases  in  which  I  have  ascer- 
tained the  point  of  commencement,  it  was  in  13  cases  the  vulva,  17  the 
arm  after  vaccination,  7  the  leg,  6  the  face,  3  the  male  genital  organs, 
3  at  or  near  the  ear,  1  the  elbow,  1  the  shoulder,  1  the  nates,  1  the 
foot.  In  the  adult,  idiopathic  erysipelas  commonly  commences  upon 
the  face,  and  aifects  only  the  face,  ears,  forehead,  and  scalp.  On  the 
other  hand,  in  infantile  erysipelas,  statistics  show  that  the  rash  com- 
mences upon  the  face  only  in  a  small  proportion  of  cases,  one  in  nine, 
and  that  it  rarely  extends  to  the  face  when  it  commences  in  other  parts. 

Causes. — In  erysipelas  the  first  departure  from  the  healthy  state 
occurs  in  the  blood,  or  the  system  generally.  This  undergoes  certain 
changes  which  predispose  to  erysipelas,  or  are  sufficient  in  themselves  to 
give  rise  to  it.  Among  the  causes  which  produce  this  state  of  system, 
uncleanliness,  residence  in  damp,  dark,  and  crowded  apartments,  and 
defective  alimentation,  hold  a  principal  place.  Hence  this  disease  is 
more  common  in  the  poor  quarters  of  a  city  than  in  the  country,  and 
in  dispensary  and  hospital  than  in  family  practice. 

In  a  large  proportion  of  cases  there  is  a  local  exciting  cause  of  in- 
fantile erysipelas,  to  wit,  an  irritation  or  inflammation  at  some  point, 
generally  trivial,  but  which  is  sufficient  to  develop  the  disease  in  the 
system  already  prepared  for  it.  It  commonly  commences  at  or  near 
a  simple  ecthymatous  or  impetiginous  eruption,  around  burns  or  sup- 
purating sores  or  sy])liilitic  eruptions ;  it  frequently  commences,  as 
is  seen  by  the  above  table,  near  the  point  of  vaccination  immediately 
after  vaccination,  or  when  the  pock  is  developed,  or  again  when  it  has 
run  its  course  and  been  detached.  In  a  considerable  proportion  of 
cases  it  begins  at  a  point  where  the  skin  is  thin  and  delicate,  or 
where  it  unites  with  a  mucous  surfiice,  probably  from  some  uncleanli- 
ness or  irritation  of  those  parts.  Thus,  I  have  records  of  cases  in  which 
it  commenced  at  the  external  ear,  commissure  of  the  mouth,  and  at  the 
vulva.  Indeed,  the  frequency  with  which  it  commences  at  the  vulva 
renders  female  infants  more  liable  to  it  than  males.  In  some  instances 
erysipelas  begins  without  any  local  exciting  causes,  upon  smooth  and 
sound  skin,  even  Avhen  there  are  sores  upon  various  parts  of  the  surfoce. 

Vaccination,  as  an  exciting  cause  of  erysipelas,  demands  particular 
notice.  Often,  doubtless,  it  is  the  inflammation  which  necessarily  arises 
from  the  cut  or  the  vesicle,  which  operates  as  an  exciting  cause  of  the 
erysipelatous  affection,  and  not  any  deleterious  property  contained  in 
the  virus  which  is  employed,  so  that  an  equal  degree  of  inflammation 
occurring  in  any  other  way,  as  from  a  burn,  would  be  attended  by  a 
like  result.  But  facts  show  that  the  virus  itself  occasionally  contains  a 
latent  noxious  ])rinci])le,  which,  introduced  into  the  system,  operates  as 
a  cause  of  erysipelas.  Thus,  a  little  girl  Avas  vaccinated  by  me  in 
November,  18(30,  and  about  the  time  when  the  vesicle  began  to  fill  she 
was  seized  with  severe  inflammation  of  the  fauces,  attended  by  tumefac- 
tion and  infiltration  of  the  submucous  connective  tissue.     The  inflam- 


CAUSES.  4:07 

mation  rapidly  subsided,  and  within  a  week  from  its  commencement  the 
throat  affection  liad  nearly  or  quite  disappeared.  I  now  believe  that 
the  disease  of  the  fauces  was  erysipelatous,  although  it  was  not  suspected 
at  the  time  to  have  this  character. 

As  the  girl  was  otherwise  healthy,  and  the  vaccine  vesicle  passed 
through  its  usual  stages,  and  presented  the  usual  appearance,  the  scab 
was  employed  six  weeks  afterward  to  vaccinate  two  infants.  Within 
twenty-four  hours  after  vaccination  both  these  infants  were  seized  with 
high  fever,  ushering  in  severe  erysipelas,  commencing  in  one  around 
the  point  of  vaccination,  and  in  the  other  around  syphilitic  sores  near 
the  anus.  In  the  former  case  tlie  erysipelatous  rash  extended  from  the 
shoulder  over  the  entire  limb,  and  was  obstinate,  twice  reappearing,  and 
extending  over  the  same  surface  ;  in  the  latter  (a  mulatto  child)  it 
extended  over  both  lower  extremities  and  a  considerable  part  of  the 
trunk,  when  the  case  passed  into  the  hands  of  another  physician,  and 
the  result  is  not  known.  The  instrument  with  which  the  vaccinations 
were  performed  was  clean.  The  vaccine  disease  did  not  appear  in  either 
of  these  cases. 

Again,  a  well-known  physician  of  this  city  vaccinated  three  infants, 
one  his  own  (No.  32  of  the  table),  with  part  of  a  scab  which  had  been 
pronounced  good,  but  was  taken  from  a  child  that  he  had  not  seen,  and 
with  whose  state  he  was  not  familiar.  These  infmts  were  all  aff'ected 
with  erysipelas  from  the  vaccination,  his  own  dying.  He  had  taken 
the  precaution  to  rub  the  lancet  on  his  boot  before  using  it.  Another 
physician  of  his  city  has  informed  me  that  he  vaccinated  two  children 
in  the  same  family  with  a  scab,  with  all  the  precautions  that  he  ever 
had  used,  and  both  were  soon  after  affected  with  erysipelas  of  a  severe 
form,  extending  from  the  point  of  vaccination  ;  the  vaccine  disease  did 
not  appear.  I  have  heard  of  no  case  in  which  the  vaccine  lymph  gave 
rise  to  erysipelas,  and  probably  it  rarely  or  never  does.  In  the  lymph 
there  is  no  admixture  of  foreign  substances,  whereas  in  the  scab  there  is 
a  large  proportion  of  animal  matter. 

There  is  a  form  of  erysipelas  which  occurs  in  the  infant  immediately 
after  birth,  and  which  is  sometimes  mot  in  private  practice,  but  is  most 
frcfjuently  observetl  as  an  ejjidemic  in  lying-in-wards.  It  is  associated 
with  severe,  and  commoidy  fatal,  |)uc'rpei'al  c)r  septic  fever,  or  erysi])elas 
of  the  mother.  This  form  of  erysipelas  is  fatal,  almost  without  excep- 
tion, and  its  contagiousness  is  generally  admitted  by  those  who  have 
had  opportunity  to  observe  cases. 

A  case  sliowing  the  relation  of  erysipelas  in  the  newly  born  infant  to 
disease  of  the  mother  occurred  in  the  practice  of  Dr.  Learning,  of  this 
city,  A  woman  gave  birth  to  a  healthy  infant,  on  the  27th  of  'luly, 
liSGO.  A  few  days  subscfiuently  she  was  seized  with  a  chill,  f(>llowe<i 
by  erysipeliis,  commencing  on  the  thighs,  and  terminating  fatally 
August  17th.  As  no  autopsy  was  allowed,  the  state  of  the  internal 
organs  was  not  ascertaine<l.  A  few  days  before  her  death  the  same 
disease  ccjmnienced  on  the  infant.  It  extended  around  the  neek,  upon 
tlie  ears,  down  the  arms,  and  termijiate<l  fatally  August  24th.  lint 
erysipelas  in  the  newborn  infant,  occurring  in  connection  with  erysipelas 
in  the  mother,  is  more  rare  than  its  occurrence  with  puerperal  fever. 


408  ERYSIPELAS. 

The  records  of  lying-in  asylums  furnish  many  examples  of  epidemics 
of  puerperal  fever,  in  which  the  infants  of  affected  mothers  perish  of 
erysipelas. 

The  late  Dr.  Folsom,  of  this  city,  furnished  me  the  following  sketch 
of  cases  which  occurred  in  his  practice  and  that  of  his  partner  :  "  About 
the  year  1840,  being  then  in  practice  in  New  Bedford,  Mass.,  I  was  called 
to  visit  a  man  who  complained  of  pain  in  the  knee.  The  next  morning 
he  was  easier,  but  the  following  evening  his  symptoms  grew  worse,  and 
as  I  was  engaged  in  a  case  of  obstetrics,  my  partner,  Dr.  E.  C,  now 
dead,  visited  him.  At  my  call,  next  morning,  I  unexpectedly  found 
the  patient  dying.  The  disease  was  obscure,  and  at  the  autopsy  next 
day  no  lesion  was  discovered.  In  making  the  examination.  Dr.  C. 
pricked  his  finger,  and  experiencing  little  inconvenience  from  it  at  first, 
he  attended  a  case  of  confinement  on  tlie  following  morning.  A  few 
hours  subsequently  he  was  taken  sick,  and  I  took  charge  of  the  lady, 
who  died  in  three  days,  having  the  tumid  abdomen  and  symptoms  of 
chihlbed  fever.  The  infant  of  the  patient  was  seized,  when  two  days 
old,  Avith  erysipelas,  appearing  on  the  face  and  in  spots  on  the  trunk 
and  limbs,  and  terminating  fatally  in  one  day.  Dr.  C.'s  finger  became 
swollen  and  painful,  and  the  lymphatics  of  the  forearm  and  arm  became 
inflamed,  presenting  red  lines,  and  the  axillary  glands  suppurated. 
Though  feverish  and  much  prostrated,  there  was  no  appearance  of  ery- 
sipelas in  his  case.  In  about  two  weeks  he  resumed  practice,  and  as  at 
that  time  physicians  in  this  country  were  not  fully  aware  of  the  danger 
of  communicating  puerperal  fever,  he  attended  two,  three,  or  four 
obstetrical  cases  each  week,  until  the  number  reached  fifteen.  All  the 
mothers  died  with  symptoms  of  metro-peritonitis,  and  all  the  infants  had 
erysipelas,  commencing  on  the  fiice  or  some  part  of  the  body,  generally 
on  the  second  or  third  day  after  birth,  and  in  all  terminating  fatally 
within  a  week.  This  sad  record  Avas  finally  ended  by  the  doctor's  tem- 
porarily retiring  from  practice." 

Dr.  Condie'  says :  "  Erysipelas  of  infants  very  commonly  occurs 
during  the  prevalence  of  epidemic  puerperal  fever.  Children  of 
mothers  who  become  affected  with  the  fever  are  often  born  with  ery- 
sipelatous inflammation ;  others  are  attacked  almost  immediately  after 
birth.  Whether,  in  these  cases,  the  disease  is  to  be  referred  to  a 
morbid  matter  applied  to  the  skin  in  the  womb,  or  to  the  same  epi- 
demic or  endemic  influence  which  gives  rise  to  the  disease  of  the 
parent,  it  is  difficult  to  say.  According  to  M.  Trousseau,  infantile 
erysipelas  is  principally  observed  Avhen  puerperal  fever  prevails  in  the 
wards  of  the  lying-in  hospitals  at  Paris."  In  private  practice  it  is  )-are 
that  we  meet  erysipelas  of  the  infant  associated  with  erysipelas  or  with 
puerperal  fever  in  the  mother.  Some  of  the  oldest  physicians  of  this 
city,  with  whom  I  have  conversed,  and  who  are  engaged  in  extensive 
general  practice,  state  that  they  have  never  met  a  case  in  which  there 
was  this  relation.  Cases  like  those  observed  by  Drs.  Folsom  and  Leam- 
ing  only  occur  when  epidemic  erysipelas  or  puerperal  fever  is  prevailing. 

According  to  Ziegler,  erysipelas  is  produced  by  a  micrococcus  which 

'  Treatise  on  Diseases  of  Children. 


SYMPTOMS.  409 

enters  the  lymphatics  and  spreads  chiefly  by  them.  They  are  found  in 
immense  masses,  or  swarms,  in  the  lymphatics,  and  from  them  they 
spread  into  the  tissues,  where  they  excite  inflammation  and  often  tissue 
necrosis. 

Premonitory  Symptoms. — Infantile  erysipelas  in  certain  cases  has 
no  premonitory  stage,  or,  if  present,  it  escapes  notice.  In  other  in- 
stances there  are  well-marked  precursory  symptoms,  as  drowsiness,  or 
restlessness,  febrile  movement,  oppressed  respiration,  with  perhaps 
vomitins,  and  startinsc  or  twitchincj  of  the  limbs.     In  Cases  2S  and  37 

o  o  o  ^ 

of  the  table,  which  occurred  in  my  practice,  the  febrile  mov^ement,  rest- 
lessness, and  oppressed  respiration  were  so  great  for  three  days  before 
the  appearance  of  the  eruption,  as  to  cause  much  anxiety.  In  the 
adult,  pharyngitis  often  precedes  the  occurrence  of  the  rash  upon  the 
skin.  The  same  inliainmation  miy  be  present  in  the  premonitory 
period  of  infantile  erysipelas,  as  well  as  during  the  period  of  erysipe- 
latous eruption.  The  hurried  and  difificult  respiration  which  is  present 
in  the  commencement  of  some  cases,  is  probably  due  to  an  erysipelatous 
turgescence  of  the  bronchial  mucous  mouibrane. 

Symptom.-!. — The  patient  with  this  disease  is  usually  restless,  in  con- 
sequence of  the  burning  pain  which  accompanies  the  eruption.  In 
severe  cases  there  is  little  sleep,  night  or  day,  except  from  medicine. 
The  sleep  is  short,  and  is  often  interrupted  by  sudden  starting  or 
twitching  of  the  limbs.     Convulsions  may  occur,  but  are  not  common. 

Febrile  movement  is  constant,  and  is  proportionate  to  the  extent  and 
gravity  of  the  erysipelas.  I  have  notes  of  cases  in  which  the  pulse  was 
more  than  200  per  minute,  although  other  symptoms  did  not  indicate 
immediate  danger.  The  skin  not  affected  by  erysipelas  is  dry  and  hot, 
though  not  possessing  the  pungent  heat  of  the  inflamed  portion ;  face 
often  flushed ;  tonirue  moist,  and  covered  with  a  liLrht  fur ;  stomach 
usually  retentive.  The  state  of  the  bowels  varies;  sometimes  they  are 
regular;  sometimes  variable,  Avhile  in  other  cases  the  stools  are  green, 
ami  more  trequent  than  natural.  I  have  records  relating  to  the  state 
of  the  bowels  in  twenty  cases,  as  follows :  in  seven,  regular ;  in  nine, 
loose;  in  two,  constipated;  in  one,  constipated,  then  loose;  and  in  one, 
constipated,  then  regular.  Diarrhoea,  when  present,  is  usually  mild, 
rcrpiiring  little  or  no  treatment.  The  erysipelatous  redness  is  not  in  all 
cases  so  pronounced  as  in  the  adidt,  but  otherwise  there  is  nothing 
peculiar  in  its  appearance.  In  feeble  infants,  with  an  impoverished 
state  of  the  blood,  its  color  is  pink,  instead  of  the  deep  red  which  char- 
acterizes the  inflammation  in  the  robust.  Points  of  vesication  may 
occur  where  the  inflammation  is  most  severe,  as  in  the  adult,  and  subse- 
<{U(Mitly  the  same  des((uamatii)U  and  oedema. 

If  the  infant  bi;  dtihilitated,  there  is  great  danger  of  the  formation  of 
abscesses,  around  which  the  inflammation  lingers  after  it  has  disappeared 
from  every  other  part  of  the  body.  Sometimes  also,  in  very  young 
infants  gangrene  occurs,  esj)ecially  in  the  genital  organs  in  the  male. 
Several  of  these  cases  have  been  related  to  me,  all  under  the  age  of  a 
month  or  six  weeks,  and  all  fatal.  Occasionally  the  sloughing  is  so 
great  as  to  denude  the  testicle.  A.  noteworthy  feature  of  erysipelas  in 
infants  is  its  proneness  to  return.      When  it   has   been  progressively 


410  ERYSIPELAS. 

subsiding,  and  hope  is  entertained  of  its  speedy  disappearance,  it  iiot 
infrequently  is  suddenly  relighted  from  some  unknown  cause,  travelling 
again  over  the  same,  or  parts  of  the  same  surface.  In  one  case  the 
disease,  arising  from  vaccination,  extended  three  times  over  the  arm  and 
forearm ;  and  in  another  case,  a  second  time  over  both  legs  and  a  con- 
siderable part  of  the  trunk. 

The  internal  inflammations  which  most  frequent  complicate  erysipelas, 
and  give  rise  to  symptoms  which  are  superadded  to  those  pertaining  to 
the  erysipelas,  are  pharyngitis  and  peritonitis  ;  and  more  rarely  broncho- 
pneumenia  or  enteritis.  In  a  case  which  I  examined  after  death,  in  the 
Nursery  and  Child's  Hospital,  and  in  which  the  erysipelatous  inflam- 
mation having  extended  over  the  abdomen,  the  lesions  of  peritonitis 
were  present,  it  appeared,  from  the  thinness  of  the  abdominal  walls, 
that  the  inflammation  had  extended  through  the  parietes  from  the  ex- 
ternal to  the  internal  surface. 

Prognosis. — Erysipelas  is  much  more  fatal  in  infancy  than  in  adult 
life.  In  the  death  statistics  of  this  city  for  three  years,  I  And'  eighty 
deaths  from  erysipelas  of  infants  under  the  age  of  one  year,  to  eighty- 
three  deaths  from  this  disease  above  that  age.  Age  greatly  influences 
the  prognosis.  Infants  under  the  age  of  three  weeks  usually  die ;  from 
the  age  of  three  weeks  to  six  months  the  result  is  doubtful ;  while  above 
the  age  of  six  months  a  majority  recover  with  correct  treatment.  It  will 
be  seen  by  the  foregoing  table  that  seven  infants  under  the  age  of  six 
Aveeks  had  erysipelas,  and  six  died ;  from  the  age  of  six  Aveeks  to  six 
months,  six  recovered  and  nine  died ;  and  above  the  age  of  six  months, 
nine  recovered  and  four  died. 

With  the  exception  of  a  case  of  the  so-called  umbilical  erysipelas,  the 
youngest  child  who  recovered,  of  whom  I  have  obtained  information,  Avas 
three  weeks  old.  In  this  case  the  rash  extended  nearly  over  the  entire 
surface,  beginning  with  the  face.  Case  38  of  the  table,  treated  by  my- 
self, Avas  very  similar  as  regards  the  extent  of  the  erysipelatous  eruption 
and  the  result.     This  inflmt  Avas  five  Aveeks  old. 

It  is  scarcely  necessary  to  state  that  erysipelas  is  more  favorable  when 
it  affiects  the  limbs  tlian  Avhcn  it  invades  the  head,  neck,  or  body  ;  when 
it  spreads  slowly  than  rapidly;  Avhen  it  is  superficial  than  Avhen  yjhleg- 
monous.  In  those  cases  in  Avhich  the  connective  tissue  is  much  in- 
A'olved,  the  infant  is  not  ahvays  safe  after  the  disease  has  run  its  course; 
he  sometimes  dies  exhausted  from  the  discharge  of  abscesses;  I  have 
records  of  tAVo  such  cases. 

DuRATiox. — In  sixteen  cases  that  recovered,  the  erysipelas  terminated 
Avithin  the  first  Aveek  in  two,  the  second  Aveek  in  six,  the  third  Aveek  in 
five,  fourth  Aveek  in  one,  and  in  two  cases  it  lasted  five  and  six  weeks. 
The  aA^erage  duration  Avas  fifteen  days.  In  nineteen  fatal  cases,  ten 
died  Avithin  the  first  Aveek,  five  the  second  week,  three  the  third  AA^eek, 
and  one  in  the  fourth  Aveek.  The  average  duration  of  fatal  cases  was 
about  ten  days. 

Modes  op  Death. — Death  occurs  in  different  ways;  in  clonic  or 
tonic  convulsions  followed  l)y  coma,  from  exhaustion,  and  from  internal 
inflammation;  that  from  exhaustion  being  probably  the  most  common. 

Pathological  Axato.aiy. — The  blood  doubtless  in  this  disease  under 


TREATMENT.  411 

goes  certain  pathological  alterations  previously  to  the  occurrence  of  the 
eruption,  but  the  exact  changes  are  not  known.  Our  knowledge  of  the 
morbid  anatomy  of  erysipelas  relates  chiefly  to  the  local  affections, 
which,  with  the  exception  of  the  inflammation  of  the  skin,  are  not  con- 
stant, and  may,  therefore,  be  regarded  as  complications.  The  cutaneous 
inflammation  aftects  all  the  structures  of  the  skin,  and  in  greater  or  less 
degree  also  the  subcutaneous  connective  tissue.  The  inflammation  is 
accompanied  by  more  or  less  serous  effusion  or  oedema. 

The  not  infrequent  occurrence  of  peritonitis  in  connection  with  ery- 
sipelas has  long  been  known.  In  Heberden's  Epitome  Morboruiii 
Puerilium,  the  anatomical  character  of  erysipelas  is  expressed  in  one 
sentence:  ''  When  the  body  has  been  opened  after  death,  the  intestines 
have  been  found  glued  togetlier  and  covered  with  coagulable  lymph." 
Since  Heberden's  time,  nearly  all  who  have  written  on  diseases  of  infancy 
and  childhood  have  mentioned  peritonitis  as  one  of  the  most  common 
complications.  Underwood  says:  "Upon  examining  several  bodies 
after  death,  the  contents  of  the  bodv  have  freciuentlv  been  found  arlued 
together  and  their  surface  covered  with  inflammatory  exudation,  exactly 
similar  to  that  of  women  who  have  died  of  puerperal  fever."  Similar 
remarks  in  reference  to  the  frequency  of  peritonitis  in  this  disease  are 
made  by  recent  writers. 

The  statistics  in  reference  to  erysipelas  as  weW  as  peritonitis  show 
that  in  infants  in  hospital  practice,  and  in  those  affected  by  erysipelas 
during  epidemics  of  puerperal  fever,  peritonitis  is  a  not  infrequent  com- 
plication. On  the  other  hand,  as  we  commonly  meet  cases  of  infantile 
erysipelas  occurring  sporadically  in  private  practice,  abdominal  dis- 
tention and  tenderness  are  not  sufficient  to  indicate  peritonitis  In 
only  one  of  the  cases  embraced  in  the  foregoing  table  was  a  post-mortem 
examination  made,  and  in  that  there  had  been  no  peritonitis.  The 
occurrence  of  pharyngitis  in  connection  with  erysipelas  has  been  already 
mentioned. 

Enteritis  has  been  alluded  to  as  another  complication  in  infants. 
DiarrJKca  lias  been  stated  to  be  a  symptom  in  certain  cases,  and  it  has 
been  found  to  be  dependent  on  enteritis  of  a  mild  grade.  Billard  made 
post-mortem  examinations  of  sixteen  infants  who  died  of  erysi])e]as,  and 
"found  in  two  gastro-etiteritis,  in  ten  enteritis,  in  three  ))neunionia 
complicated  with  enteritis  and  cerebral  congestion,  and  in  one  pleuro- 
pneumonia." 

TiiEAT.MENT. — On  this  side  of  the  Atlantic  great  uniformity  prevails 
as  regards  the  treatment  of  erysipelas.  Sustaining  measures  arc  pre- 
scribed, an<l  the  tincture  of  the  cliloride  of  iron  is  the  tonic  generally 
preferred.  Whatever  the  intensity  of  the  febrile  reaction  and  the  stage 
of  the  disea-e,  if  there  be  no  intestinal  complication,  ferruginous  or  other 
tonics  should  be  administered.  The  larwst  doses  of  the  tincture  of  the 
chloride  of  iron  given  in  any  of  the  cases  in  the  above  table  were  in  Ciise 
No.  4,  namely,  ten  dro|)S  every  two  hours,  and  this  patient  recovereil  in 
seven  days  from  a  pretty  severe  attack.  Probably,  however,  nothing  is 
gained  by  such  largo  doses,  and  they  may  irritate  the  intestinal  surface, 
an!  increase  the  lial)ility  to  enteritis,  which,  we  have  seen,  eomplicates 
a  certain  proportion  of  cases.     Four  drops  may  bo  given  every  three 


412  ERYSIPELAS. 

hours  to  a  child  from  one  to  two  years  of  age.  Instead  of  the  iron,  or  m 
addition  to  it,  one  of  the  preparations  of  cinchona  may  be  prescrib<;d. 
Beef-tea,  and  wine-whey  or  other  alcoholic  stimulant,  are  required. 

The  depressing  measures  recommended  by  certain  writers  cannot  be 
too  strongly  censured.  One  author  says:  "  We  should  endeavor  from 
the  first  to  allay  the  inflammation  of  the  skin  by  energetic  treatment. 
Local  abstraction  of  blood,  by  means  of  one  or  two  leeches 
applied  at  the  circumference  of  the  primary  seat  of  the  erysipelas,  should 
be  put  in  force,  provided  the  power  of  the  constitution  of  the  children 
permits."  Such  treatment  may  explain  one  of  this  author's  aphorisms, 
namely,  the  erysipelas  of  infants  is  a  fatal  disease. 

Local  treatment  may  be  employed  to  arrest  the  extension  of  the  in- 
flammation, but  the  result  in  most  cases  is  not  encouraging.  Solid 
nitrate  of  silver  was  employed  in  two  cases  of  which  I  have  records, 
and  in  both  the  result  was  pernicious.  Troublesome  sores  were  pro- 
duced, from  which  blood  escaped,  and  in  one  of  the  cases,  at  least, 
death  was  attributed  by  the  parents  to  this  treatment,  rather  than  to 
the  disease. 

Tincture  of  iodine  is  a  better  remedy  for  arresting  the  extension  of 
erysipelas.  It  should  be  applied  from  the  margin  of  the  inflammation, 
over  the  sound  skin,  to  the  distance  of  about  two  inches.  It  may  be  in- 
effectual, but  it  does  not  produce  any  unfavorable  result.  Sootliing 
applications,  like  rye  flour,  or  a  lotion  of  sugar  of  lead,  may  be  made  to 
the  inflamed  surface,  as  in  erysipelas  of  the  adult.  I  prefer,  however, 
for  local  treatment,  the  constant  application  of  vaseline  or  glycerine  and 
water,  to  which  carbolic  acid  is  added — one  to  ten. 


PART  III. 
SECTION  I. 

DISEASES  OF  THE  CEREBROSPINAL  SYSTEM. 

Diseases  of  the  brain  and  spinal  cord  are  less  frequent  than  those 
of  the  respiratory  and  digestive  systems.  They  are  also  less  amenable 
to  treatment,  and  are  much  more  fatal.  They  largely  increase  the 
aggregate  of  deaths.  They  contrast  with  the  diseases  of  tlie  other 
systems  in  their  greater  relative  frequency  in  infancy  and  childhood 
than  in  adult  life.  This  is  explained,  as  regards  the  brain,  by  the  rapid 
development  and  active  molecular  change  in  this  organ  in  early  life,  its 
great  impressibility  by  the  emotions,  and  the  thinness  of  the  covering 
Avhich  protects  it  from  external  agencies. 

Some  of  the  most  interesting  of  the  cerebro-spinal  diseases  which  are 
to  engage  our  attention,  are  peculiar  to  early  life,  as  tetanus  infantum. 
The  diseases  of  this  system  also  contrast  with  other  local  affections  in 
their  greater  obscurity,  especially  in  their  commencement;  for,  while 
maladies  of  the  thorax  can  be  readily  ascertained  by  auscultation  and 
percussion,  or  those  of  the  abdomen  by  the  nature  of  the  evacuations  or 
the  degree  of  tenderness  or  distention,  our  means  of  conducting  exami- 
nation tlirough  the  bony  encasement  of  the  cerebro-spinal  axis  are 
meagre  and  unsatisfactory.  The  condition  of  the  brain  and  spinal  cord 
must  be  determined,  chiefly,  by  the  study  of  symptoms,  and  not  by 
direct  examination.  The  condition  of  tlie  anterior  fontanelle  in  young 
infants,  however,  enables  us  to  determine  tlie  presence  or  absence  of 
active  congestion  of  tlie  brain.  If  there  be  an  excess  of  arterial  Idood, 
it  is  convex.  Prominence  of  the  fontanelle  is  common  in  inflammatory 
and  febrile  diseases,  and  is  a  sign  of  considerable  diagnostic  and  prog- 
nostic value. 

Within  a  few  years,  the  ophthalmoscope  has  been  employed  as  a 
means  of  diagnosis  in  cerebral  diseases,  and  although  the  employment 
of  this  instrument  for  such  })urpose  is  but  recent,  enough  lias  been 
elicited  to  prove  its  value  as  an  aid  in  determining  the  state  of  the 
brain.  Prof.  II.  D.  Noyes  remarks  on  this  subject:  .  .  .  "The 
argument  for  making  oi»hthalmoscoi)ic  examination  in  all  cases  of  ])rain 
(Usease,  becDmes  irresistible.  Indeed,  a  mf)inent"s  reflection  would  lead 
to  this  conclusion  without  any  considerations  drawn  from  pathology. 
The  optic  nerve  is  only  an  outlying  portion  of  the  brain;  its  extremity 
is  fully  exposed  to  view.  Situated  within  about  two  inches  of  the  brain, 
it  is  the  only  nerve  in  the  body  which  wc  can  inspect;  it  contains 

(  413  ) 


414:  DISEASES    OF    THE    CEREBRO-SPIN AL    SYSTEM. 

bloodvessels  which  communicate  directly  with  the  intracranial  circula- 
tion. We  thus  come  into  relation  with  the  cerebrum,  by  continuity  of 
nerve-structure  and  also  of  bloodvessels." 

Structural  changes  in  the  optic  nerve  and  retina  have  been  discov- 
ered by  means  of  the  ophthalmoscope  in  meningitis,  hydrocephalus, 
phlebitis  of  the  sinuses,  apoplexy,  etc.  Among  the  lesions  which  have 
been  observed  by  this  instrument,  are  hypememia,  more  or  less  opacity 
and  tumefaction  of  the  optic  nerve,  engorgement  of  the  vessels  of  the 
retina,  with  serous  or  sero-fibrinous  exudation  and  ecchymotic  ])oints. 
In  certain  protracted  diseases,  as  chronic  hydrocephalus,  in  which  dim- 
ness or  loss  of  siglit  occurs,  the  ophthalmoscope  discloses  a  state  of  atrophy 
of  the  optic  nerve.  Heretofore  this  instrument  has  been  chiefly  em- 
ployed by  oculists,  but  as  it  comes  into  more  general  use,  there  can  be 
little  doubt  that  it  will  be  recognized  as  an  important  aid  in  the  diag- 
nosis of  obscure  cerebral  diseases. 

Still,  with  all  possible  aids  to  diagnosis,  the  obscurity  which  attends 
the  invasion  of  many  of  the  ccrebro-spinal  diseases  must  be  acknowl- 
edged. To  the  hasty  and  careless  physician,  their  symptoms  are  often 
deceptive.  Careful  weigliing  of  the  phenomena,  and  thorough  and  pro- 
tracted examination,  are  requisite  in  order  to  insure  correct  diagnosis 
and  proper  treatment.  Some  of  the  cerebro-spinal  affections  are,  in 
reality,  se(|ucl<Te  of  other  diseases,  as,  for  example,  spurious  hydrocepha- 
lus; and  some  are,  strictly  speaking,  only  symptoms,  as  convulsions; 
but,  on  account  of  their  importance,  and  because  they  require  special 
treatment,  it  is  proper  to  consider  them  as  diseases  per  se. 

The  brain  presents  certain  peculiarities  in  infancy  and  childhood.  In 
the  ffjetus,  while  the  other  organs  are  Avell  formed,  the  brain,  especially 
its  cerebral  portion,  is  still  diffluent,  and  at  birth  it  has  so  little  con- 
sistence that  it  must  be  handled  carefully  to  prevent  laceration.  This 
softness  is  due  to  the  large  pi'oportion  of  water  which  it  contains. 
The  following  analyses  show  the  composition  of  the  brain  in  three 
periods  of  life : 

Infant. 
Albumen        ......       7.00 

Cer(!hral  fats  .....       3.45 

Phosphorus 0.80 

Osmazome,  salts   .         .         .         .         .       5  90 
"Water 82.79 

At  birth  the  brain  has  a  nearly  uniform  white  color.  The  gray  sub- 
stance, in  which  the  nervous  power  originates,  is  undeveloped.  The 
date  of  its  appearance  corresponds  with  the  first  exhibition  of  emotion 
or  intelligence,  and  the  decided  gray  color  which  we  observe  in  the 
brain  of  the  adult  does  not  appear  until  the  age  of  full  mental  activity. 

In  the  newborn  the  brain  is  large  in  proportion  to  the  rest  of  the 
body,  and  its  growth  during  infancy  and  childhood  is  rapid.  Until  the 
fifth  year,  as  appears  from  the  observations  of  Dr.  Peacock,  its  weight 
is  about  one-seventh  or  one-eighth  that  of  the  entire  system,  the  pro- 
portions varying  somewhat  in  dift'erent  cases. 

The  brain  does  not  attain  its  full  size,  as  stated  by  Dr.  West,  at  the 
age  of  seven  years,  but,  according  to  Dr.  Peacock's  statistics,  it  con- 


Youth. 

Adult. 

10.20 

9.40 

5.30 

6.10 

1  65 

1.80 

8.59 

10.19 

74  2G 

72.51 

ACEPHALUS  —  ANENCEPHALUS.  415 

tinues  to  increase  till  the  age  of  twenty-five  or  thirty,  although  its 
growth  is  less  rapid  after  the  age  of  seven  years  than  previously. 

The  membranous  covering  of  the  cerebro-spinal  axis  is  scarcely  less 
interesting  to  the  pathologist  than  the  axis  itself.  I  shall  speak  in  the 
following  pages  of  the  arachnoid  and  cavity  of  the  arachnoid,  for  conve- 
nience of  description,  although  aware  of  the  fact  that  some  eminent 
authorities,  as  Yirchow  and  Kolliker,  whose  opinions  in  reference  to  the 
minute  anatomy  of  the  system  ahvays  command  attention,  if  not  assent, 
believe  that  there  is  no  arachnoid,  but  what  has  heretofore  been  called 
by  this  name  is  on  the  one  side  the  smooth  surface  of  the  dura  mater 
and  on  the  other  of  the  pia  mater. 

The  dura  mater  is  seldom  involved  in  the  diseases  of  early  life,  except 
as  it  is  aifected  by  pressure,  while  the  pia  mater  and  arachnoid  are  the 
seat  and  source  of  some  of  the  most  important  diseases,  as  meningitis, 
meningeal  apoplexy,  etc. 

The  more  complicated  and  delicate  the  structure  of  an  organ,  the 
more  liable  it  is  to  errors  of  nutrition  and  groAvth'.  There  is,  therefore, 
no  organ  which  is  so  liable  to  irregular  development  as  the  brain.  It 
may  be  entirely  wanting ;  or  it  may  be  partially  developed,  certain 
portions  being  absent;  or,  lastly,  its  growth  may  be  excessive,  consti- 
tuting hypertrophy. 


CHAPTER    I. 

ACEPHALUS— AXENCEPIIALUS. 

Entire  absence  of  the  encephalon  is  not  common,  but  there  are  many 
cases  of  tliis  monstrosity  on  record.  In  extreme  cases  the  head  and 
piirt  of  the  neck,  as  well  as  the  brain  and  medullaoblongata,  are  absent. 
When  there  is  great  deficiency  there  is  often  a  twin,  the  presence  of 
which  has  interfered  with  the  full  development  of  the  foetus.  Some- 
times the  groAVtli  of  other  organs  besides  the  brain  is  imperfect. 

Anatomical  Character. — In  the  ordinary  form  of  anencephalus 
the  brain  and  sometimes  the  medulhi  are  absent,  with  the  absence  or 
imj»erfect  development  of  their  membranous  and  osseous  covering.  The 
vault  of  the  cranium  is  absent.  There  is  deficiency  of  the  frontal, 
parietal,  and  occipital  bones,  except  those  portions  which  are  near  the 
base  of  the  cranium.  Tiiese  portions  are  very  thick  and  closely  united, 
as  if  there  wer^  the  usual  amount  of  osseous  substance,  but  instead  of 
expanding  into  the  arch,  it  had  collected  in  an  irregular  niiiss  at  the 
biise  of  the  cranium. 

The  absence  of  the  brain  and  the  cranial  arch  gives  a  remarkable 
appearance.  The  eyes  are  prominent,  the  neck  thick  and  short,  while 
the  body  and  limbs  are  ordinarily  well  developed.  The  physiognomy 
has  been  compared  to  that  of  some  of  the  lower  animals. 


416  ACEPHALUS  —  ANEN  CEP  H  ALUS. 

The  base  of  the  cranium  is  often  occupied  by  a  vascuhar  tumor,  not 
large,  but  of  dift'erent  .size  in  ditferent  ca.ses,  and  continuous  below  with 
the  spinal  pia  mater.  The  vascular  tumor  is  the  representative  of  the 
cranial  pia  mater,  and  its  smooth  surface  is  the  analogue  of  the  arach- 
noid. The  dura  mater  and  the  scalp  being  absent,  the  exposed  mass 
resembles  very  much  in  appearance,  as  it  does  in  structure,  the  placenta, 
and  the  sensation  which  it  imparts  to  the  finger  pressed  upon  it  is  very 
similar.     Sometimes  small  portions  of  cerebral  matter  are  found  among 

Fia.  27. 


the  vessels  of  this  tumor,  but  they  are  so  disconnected  or  isolated  that 
they  do  not  perform,  in  any  way,  the  function  of  a  brain.  Occasionally 
the  vascular  tumor  is  absent  and  the  medulla  or  upper  extremity  of  the 
spinal  cord  is  exposed,  or  it  terminates  in  a  little  papilla  at  the  back  of 
the  neck. 

Those  portions  of  tlie  cranial  nerves  which  lie  external  to  the  cranium 
are  Avell  developed,  although  tlie  intracranial  parts  may  be  absent. 

Symptoms. — The  respiration  in  anencephalous  monsters  is  irregular. 
They  can  be  made  to  cry,  but  their  cry  is  a  sort  of  sob  or  hiccough,  and 
occasionally  they  even  nurse.  The  digestive  function  is  well  performed, 
and  regular  urinary  and  fecal  evacuations  occur.  There  is  a  tendency 
in  anencephalous  monsters  to  convulsions.  Blowing  upon  them,  and 
pressure  upon  the  projecting  medulla,  if  this  be  present,  frequently  ])yo- 
duce  this  effect. 

Prognosis. — Fortunately  these  monsters  are  short-lived.  If  the 
medulla  oblongata,  which  is  essential  to  the  maintenance  of  respiration, 
be  absent,  extrauterine  life  is  impossible.  Stillbirth  is  the  result.  If 
the  medulla  oblongnta  1)0  present,  altliough  respiration  and  circulation 
are  established,  death  commonly  takes  ])lace  within  two  or  three  days, 
and  almost  always  within  the  first  Aveek.  Convulsions  sooner  or  later 
occur,  ending  in  fatal  coma. 


IMPERFECT    BRAIISr.  417 


CHAPTER   II. 

IMPERFECT  BRAIN. 

Between  the  absent  and  complete  brain  there  are  various  frrades  of 
deficiency.  Parts  of  the  brain  may  be  perfect,  while  other  portions  are 
either  absent  or  imperfectly  formed.  The  deficiency  is  usually  in  the 
superior  parts  of  the  brain,  especially  in  the  hemispheres  of  the  cere- 
brum, while  the  base  of  the  organ  is  perfect.  Both  hemispheres  may 
be  absent,  or  one  may  be  absent,  while  the  other  hemisphei'e  is  shriv- 
elled or  rudimentary.  Occasionally  the  cranium  preserves  its  normal 
shape  and  size,  in  consequence  of  an  increase  in  the  cerebro  spinal  fluid 
proportionate  to  the  lack  of  brain-substance.  The  imperfect  develop- 
ment is  not  then  apparent  to  the  observer.  The  rudimentary  hemi- 
spheres in  these  cases  are  spread  out,  forming  the  walls  of  a  sac  inclosing 
the  liquid.  The  post-mortem  examination  of  the  following  case  was 
made  in  tlie  Nursery  and  Child's  Hospital,  of  this  city,  in  1862. 

Case. — Female ;  parentage  healthy  ;  she  Avas  plump  and  well  formed 
at  birth,  and  nothing  unusual  was  observed  in  her  condition,  as  she 
nursed  and  throve  like  other  children,  till  she  reached  the  age  when  there 
is,  usually,  the  first  manifestation  of  intelligence.  With  her  there  was  no 
evidence  of  any  intellect,  or,  if  any,  it  was  very  indistinct.  She  nursed, 
or  took  food  when  placed  in  her  mouth,  but  apparently  without  relish,  as 
if  instinctively.  She  never  reached  her  hands  toward  the  nurse,  or  toward 
playtliin.rs.  So  indifferent  ami  apparently  unconscious  was  she  of  objects 
around  her,  that  it  was  thought  for  some  time  that  she  was  blind.  She 
never  smiled,  exce[)t  when  her  hands  were  gently  rubbed  or  shaken  ;  and 
then  the  smile  seemed  to  be  a  movement  iiiore  reflex  than  emotional.  The 
smile  wa.s  immediately  succeeded  by  a  fixed  vacant  look.  She  usually  lay 
quietly,  with  her  arms  crossed;  and  during  the  last  month  of  her  life  she 
sometimes  uttered  a  scream,  like  children  with  cerebral  diseases.  Her 
evacuations  were  regular,  and  she  was  not  subject  to  vomiting,  before  she 
was  attacked  with  the  acute  disL-ase  of  which  she  died.  The  size  of  her 
head  wjus  rather  less  than  usual  at  her  age,  but  not  less  than  is  often  seen 
in  well-formed  children.  The  forehead  was  small  in  proportion  to  the 
rest  of  the  head,  but  the  difference  was  not  such  as  to  attract  attention. 
Fortunately,  the  existence  ot"  this  idiot  was  terminated  by  an  attack  of 
entero-colitis  at  the  age  of  about  ten  months. 

Scctio  Oidav. — The  head  was  nu-asured,  but  the  measurements  were 
lost.  They  did  not  seem  to  diflef  materially  from  the  normal  standard. 
The  sutures  wcire  united,  and  the  fontanelli's  nearly,  if  not  (|uite,  closed. 
The  frontal  bone  lay  a  little  lower  than  the  plane  of  the  parietal.  The 
meninrres  of  the  brain  ])resented  nearly  their  normal  appearance,  but  were 
distended  with  transparent  serum.  The  quantity  of  fluid  was  estimated 
at  about  two-thirds  of  a  ])int,  and  when  it  was  evacuated  the  floor  of  the 
lateral  ventricles  was  broiiirht  into  view.  There  was  an  almo.st  entire  ab- 
sence of  that  part  of  the  brain  which  lies  above  the  floor  of  the  ventricles. 


418  IMPERFECT    B'RAIN. 

On  close  inspection,  rudimentary  cerebral  hemispheres  were  found  in  a 
thin  layer  forming  a  part  of  the  walls  of  the  sac.  The  whole  amount  of 
brain-substance  above  the  ventricle  did  not  exceed  the  size  of  a  small  egg. 
The  cei'ebelluni,  the  base  of  the  brain,  and  cranial  nerves  presented  their 
usual  appearance.  The  entire  brain,  after  being  a  few  days  in  diluted 
alcohol,  weighetl  six  and  a  quarter  ounces. 

In  this  case,  the  fluid  was  only  sufficient  to  compensate  for  the 
deficiency  of  the  brain.  In  other,  and  probably  the  larger  number  of 
cases  of  incomplete  brain,  the  cerebro-spinal  fluid  is  not  materially 
increased.  There  is  then  but  slight  elevation  of  tlie  frontal  bone,  the 
forehead  is  low,  or  retreating,  or  even  almost  absent.  This  is  that 
shape  of  head  which  is  universally  regarded  as  characteristic  of  idiocy. 

Symptoms. — The  symptoms  in  cases  of  deficient  brain  relate  to  the 
mind.  If  the  cerebral  hemispheres  are  absent,  there  is  no  intelligence. 
The  individual,  as  regards  mental  endowments,  does  not  rise  above  the 
instincts  of  the  loAver  animals.  If  the  hemispheres  are  partially  devel- 
oped, there  is  a  degree  of  intelligence  proportionate  to  the  amount  of 
cerebral  substance  present.  If  the  deficiency  be  confined  to  one  side, 
there  is  no  apparent  lack  of  intelligence  or  mental  capacity,  since,  the 
brain  being  a  double  organ,  one  side  performs  the  functions  of  both. 

Prognosis. — The  prognosis  as  regards  life,  in  cases  of  imperfect 
brain,  depends  not  so  much  on  the  amount  of  deficiency  as  the  exact 
scat  of  arrested  growth.  If  only  the  cerebrum  be  partially,  or  even 
entirely  absent,  the  infant  may  live  and  thrive.  But  if  those  portions 
lying  at  the  base  of  the  brain,  Avhich  control  the  functions  of  animal 
life,  are  lacking,  or  are  imperfectly  formed,  life  is  very  uncertain,  and 
probably  short. 

It  is  evident  that  no  therapeutic  treatment  can  remedy  a  congenital 
deficiency.  The  services  of  the  physician  are  not  required.  The 
philanthropic  and  patient  teacher  may  impart  a  degree  of  intelligence 
to  the  idiotic,  and  the  instruction  of  these  unfortunates  has  of  late  years 
been  successful. 


Microcephalus — Atrophy  of  Brain. 

An  abnormally  small  brain  has  usually  been  attributed  to  premature 
closure  of  the  sutures  and  fontanelles  by  too  rapid  ossification.  But  in 
certain  cases  which  I  have  met  there  was  no  evidence  of  exaggerated 
ossification,  and  the  fault  seemed  to  me  to  be  a  deficiency  in  the  growth 
of  the  brain,  while  the  ossifying  process  was  not  exaggerated  or  was 
even  less  than  normal.  A  normal  development  of  the  cranial  bones, 
with  but  little  brain-substance  to  keep  them  apart,  would  necessitate 
early  obliteration  of  sutures  and  fontanelles.  Thus  in  August,  1878, 
an  infant  was  brought  into  the  Bureau  for  the  Relief  of  the  Outdoor 
Poor,  with  marked  microcephalism.  Its  age  was  19  months,  and  the 
bone  formation  was  so  slow  that  only  two  teetli  had  appeared  ;  the  cir- 
cumference of  its  head  was  14J  inches  ;  it  had  had  repeated  convulsions 
since  the  age  of  five  months,  and  the  mother  stated  that  its  head  had 


MICROCEPHALUS  —  ATROPHY    OF    BRAIX.  419 

been  round  and  hard  from  its  birth.  In  microcephalus,  death,  sooner 
or  later,  is  the  common  result ;  life  ends  in  convulsions  and  coma. 

Again,  the  brain  of  the  child,  when  undergoing  development,  with  the 
cranial  bones  sufficiently  yielding,  may  not  only  cease  to  grow,  but  may 
even  diminish  in  size,  in  consequence  of  protracted  and  exhausting  dis- 
seases.  Diminution  in  the  size  of  the  brain  occurs  especially  after 
fevers  and  diarrhoeal  affections  of  long  standing  and  attended  with  much 
emaciation.  The  waste  of  the  brain  corresponds  with  the  general  loss 
of  flesh.  If  the  cranial  sutures  be  not  united,  the  occipital  and  some- 
times the  frontal  bones  are  depressed,  according  to  the  diminished  size 
of  the  brain,  and  are  overlaid  by  the  parietal.  In  foundlings  of  two  or 
three  months,  this  loss  of  brain-substance  is  often  very  striking.  In 
infants  of  this  class  who  have  died  of  protracted  diarrhoea,  it  is  not 
unusual  to  observe  the  occipital  bone  not  only  depressed,  but  extending 
one,  two,  or  even  three  lines  underneath  the  parietal. 

If  the  child  with  shrunken  brain,  from  protracted  and  exhausting 
disease,  be  old  enough  to  express  its  thoughts,  it  often  seems  foolish, 
talks  but  little,  and  perhaps  says  the  same  thing  over  and  over  again. 
In  one  case  in  my  practice,  a  little  girl,  having  passed  through  a  long 
course  of  typhus,  persistently  repeated  during  her  convalescence,  with 
a  sill}^  smile,  the  questions  addressed  to  her.  This  peculiarity  con- 
tinued two  or  three  weeks,  although  her  appetite  was  good,  and  her 
restoration  to  health  rapid.  In  another  case  a  little  boy,  during  con- 
valescence, was  wont  to  laugh  heartily  at  the  appearance  of  the  or(linary 
articles  of  furniture  in  the  room.  Both  showed  more  impairment  of 
mind  during  convalescence  than  in  the  midst  of  the  fever.  The  friends 
of  such  children  are  in  a  state  of  great  anxiety  lest  their  minds  be  per- 
manently enfeebled,  but,  as  the  appetite  and  strength  return,  the  nutri- 
tion of  the  brain  is  reestablished,  and  the  mind  regains  its  former  vigor. 
In  cases  of  wasted  brain,  with  cranial  bones  united,  the  deficiency  is 
supplied  by  serous  effusion,  which  is  gradually  absorbed  as  the  health 
of  the  patient  is  reestablished,  and  the  brain  enlarges.  This  effusion 
occurs  not  only  over  the  convexity  of  the  brain,  but  also  at  its  base,  and 
sometimes  in  the  ventricles.  Dr.  West  states  that  in  atrophy  of  the 
brain,  from  protracted  disease,  its  texture  is  firmer  than  usual.  I  have 
not  noticed  this  in  infants,  but  my  attention  lias  not  been  directed  par- 
ticularly to  this  point.  It  is  probable  that  there  is  some  change  in  the 
anatomical  character  of  the  brain,  aside  from  mere  waste. 

Partial  atrophy  of  the  brain  sometimes,  also,  occurs  from  primary 
disease  located  in  this  organ  ;  the  affected  portion  wastes,  while  the  rest 
retains  its  normal  development. 


420  HYPERTROPHY    OF    BRAIN. 


CHAPTEE    III. 

HYPEKTKOPHY  OF  BPvAIN. 

In  contrast  with  atrophy  of  the  brain  is  the  opposite  state,  or  hyper- 
trophy. The  size  of  this  organ  within  the  hmits  of  health  varies  greatly 
in  different  individuals,  but  sometimes  there  is  so  great  an  increase  in 
volume  as  properly  to  constitute  a  disease.  Fortunately  hypertrophy 
of  brain  is  rare  in  America. 

Pathological  Anatomy. — The  excess  of  growth  which  characterizes 
this  disease  has  been  ascertained  to  be  confined  to  the  white  portion  of 
the  brain,  and  ordinarily  to  that  part  contained  in  the  cerebral  hemi- 
spheres. Hypertrophy  of  the  brain  is  attended  by  induration,  which 
exists  in  different  degrees  in  different  cases.  It  is  in  some  so  slight  as 
to  be  scarcely  appreciable ;  while  in  others  it  is  apparent  at  once  by 
pressure  with  the  finger,  or  incision  with  the  scalpel.  Rilliet  and 
Barthez  state  that  the  induration  in  some  cases  resembles  in  degree  and 
appearance  that  produced  by  the  action  of  alcohol.  The  white  sub- 
stance of  the  cerebrum  is  not  only  resisting  and  elastic,  but  its  color  is 
unusually  ])ale ;  it  presents  even  a  brilliant  or  polished  appearance.  At 
the  same  time  the  gray  substance  is  more  or  less  faded,  and  its  depth  in 
the  convolutions  is  less  than  in  the  normal  state  of  the  organ.  Roki- 
tansky  says  :  "  The  cineritious  matter  is  generally  of  a  pale  grayish-red 
color.  The  medullary  is  always  dazzling  white,  and  remarkably  pale 
and  anaemic."  An  unusual  case  is  related  by  Burnet,  in  which  the 
gray  substance  in  the  corpora  striata  retained  its  usual  color,  and  was 
indurated  like  the  white  substance.  In  exceptional  instances  the  cere- 
bellum as  well  as  cerebrum  undergoes  hypertrophy,  becoming  at  the 
same  time  more  or  less  indurated.  In  Burnet's  case  there  was  indu- 
ration of  the  optic  nerves.  "  The  internal  structure,"  he  says,  "  of  the 
optic  nerves,  especially  in  their  bulbs,  hnd  the  polish,  homogeneous 
appearance,  elasticity,  and  almost  the  hardness  of  cartilage."  llilliet 
and  Bartliez  state  that  in  two  cases  the  spinal  cord  presented  even  more 
marked  induration  than  the  encephalon.  Congestion  is  not  a  feature 
of  hypertrophy.  On  the  other  hand,  there  is  often  less  vascularity  of 
the  brain  and  its  membranes  than  in  the  healthy  state.  If  the  cranial 
bones  be  completely  ossified  at  the  time  wlien  hypertrophy  commences, 
and  firmly  united,  enlargement  of  the  ))rain  is  partially  prevented.  The 
convolutions  are  then  thin,  much  flattened,  the  sulci  more  or  less  effaced, 
the  membranes  pale  and  dry,  and  the  ventricles  are  small  and  nearly 
destitute  of  serum.  At  the  autopsy  of  such  a  case,  when  the  dura  mater 
is  incised,  the  expansion  of  the  brain  prevents  the  proper  refitting  of  the 
skullcap.  Occasionally  liy])ertro])hy  causes  more  or  less  absorption  of 
the  cranium,  and  perliaps  the  sutures  already  united  are  pressed  apart. 

If  hypertrophy  commence  in  young  infants  with  the  fontanelles  and 


SYMPTOMS.  421 

sutures  still  open,  they  usually  remain  open,  or  are  a  long  time  in  uniting. 
The  interspaces  continue,  not  only  in  consequence  of  the  growth  of  the 
brain,  which  tends  to  separate  the  bones,  but  also  in  consequence  of 
feeble  ossification.  The  shape  of  the  head  arrests  attention.  Hyper- 
trophy usually  produces  most  enlargement  between  and  above  the  ears, 
while  the  frontal  portion  of  the  head,  though  somewhat  enlarged,  is  less 
developed. 

The  direction  of  the  eyes  is  not  changed,  as  is  common  in  congenital 
hydrocephalus. 

Rokitansky  says  (vol.  iii.  page  28o):  "With  regard  to  the  question 
to  be  decided  by  the  theory  and  microscopic  examination,  as  to  the 
nature  of  the  added  material  upon  which  the  increase  of  volume  de- 
pends, I  have  formed  the  following  opinion  from  repeated  investigations: 

"'  1.   The  disease  is  genuine  hypertrophy. 

"2.  It  consists,  as  such,  not  in  an  increase  in  the  number  of  nerve- 
tubes  in  the  brain,  from  new  ones  being  formed,  nor  in  an  increase  in 
the  dimensions  of  those  which  already  exist,  either  as  thickening  of  their 
sheaths,  or  as  augmentation  of  their  contents,  by  either  of  which  the 
nerve-tubes  would  become  more  bulky ;  but, 

"  3.  It  is  an  excessive  accumulation  of  the  intervening  and  connect- 
ing nucleated  substance." 

It  is  now  generally  admitted  that  the  views  of  Rokitansky  arc  cor- 
rect; that  hypertrophy  of  the  brain  is  due  to  an  augmentation  in  the 
amount  of  connective  tissue  which  lies  between  and  unites  the  tubules. 

Causes. — Hypertrophy  of  the  brain  results  from  an  error  in  the 
nutritive  process  which  sometimes  seems  to  be  associated  with  the  rachitic 
state,  or  a  condition  analogous  to  rachitis.  It  is  not  common,  is  indeed 
rare,  in  this  country,  and  is  more  common  in  countries  like  England, 
where  rachitis  is  more  prevalent  than  with  us.  Rilliet  and  Barthez 
consider  frequent  congestions  of  the  brain  as  a  common  cause.  The 
hypertrophy  is  most  frequently  met  in  hospitals  for  children,  and  among 
the  poor  of  cities,  whose  systems  are  rendered  cachectic  by  residence 
in  damp  and  dark  localities,  and  by  unwholesome  diet.  In  the  deep 
valleys  of  Switzerland,  and  in  parts  of  South  America  and  Asia,  hyper- 
trophy of  the  brain  is  common,  under  the  name  cretinism.  It  is  asso- 
ciated with  rachitis  and  stunted  growth.  The  abnormal  development 
which  occurs  in  cretinism  begins  in  infancy  or  early  childhood,  and  the 
unfortunate  subjects  of  it  are  short-lived.  Cretinism  has  been  attributed 
to  a  residence  in  localities  wet  and  deprived  in  great  measure  of  solar 
light,  and  to  general  disregard  of  the  laws  of  health  on  the  part  of  those 
afllected  as  well  as  their  parents. 

The  observations  of  (lifferent  physicians  also  establish  a  connection 
between  some  cases  of  liypertroi)hy  and  the  saturation  of  the  system  by 
lead.  In  what  way  lead-jjoisoning  leads  to  hypertrophy  is  obscure,  but 
the  concurrent  testimony  of  different  observei's  is  so  strong,  that  we  can- 
not doubt  that  it  does  sometimes  liave  that  effect.  But  in  a  considerable 
proportion  of  cases,  as  in  the  one  presently  to  be  related,  the  cause  is 
obscure. 

Symptoms. — The  symptoms,  as  is  the  case  with  most  organic  diseases 
of  the  brain,  vary  considerably  in  different  patients.     Sometimes  there 


422  HYPERTROPHY    OF    BRAIN. 

is,  at  first,  more  or  less  depression  or  languor.  If  the  child  be  old 
enough  to  speak,  he  may  complain  of  })ain  in  the  abdomen  or  limbs, 
evidently  neuralgic,  or  of  headache.  After  a  variable  time  vomiting 
succeeds,  and  finally  convulsions,  affecting  the  muscles  of  the  face  as 
"vvell  as  extremities;  the  convulsions  are  usually  clonic,  but  sometimes, 
as  regards  at  least  the  extremities,  of  a  tonic  character.  The  pupils 
mav  be  contracted  or  dilated;  there  is  restlessness  alternatins:  -with 
drowsiness,  and  finally  coma  succeeds. 

Hypertrophy  may  continue  a  considerable  time  before  serious  symp- 
toms arise;  but  when  once  developed,  these  symptoms  ordinarily  con- 
tinue Avith  more  or  less  severity  till  death.  Death  commonly  results 
within  a  "sveek  after  their  commencement,  but  sometimes  not  till  several 
weeks  have  elapsed.  When  death  occurs  at  an  early  ])eriod  in  the  dis- 
ease, there  is  usually  firm  ossification  and  union  of  the  cranial  bones, 
and,  therefore,  but  moderate  enlargement  of  the  cranium. 

If  hy]iertrophy  commence  at  a  period  not  far  removed  from  birth,  the 
bones,  of  course,  yield  more  readily  to  the  pressure,  and  acute  symptoms 
do  not  occur  so  soon.  After  a  time,  however,  in  all  or  nearly  all  cases, 
convulsions  supervene.  These  indicate  the  gravity  of  the  disease,  and 
are  prognostic  of  its  fatal  termination. 

In  a  patient  observed  by  Burnet,  violent  convulsions,  followed  by  loss 
of  consciousness,  marked  the  commencement  of  acute  symptoms.  Five 
days  subsequently,  the  following  symptoms  were  recorded :  mobility  of 
the  eyes,  without  expression;  pupils  contracted,  and  directed  u{)ward; 
divergent  strabismus  of  the  left  eye ;  the  senses  in  their  noi-mal  state, 
with  the  exception  of  sight ;  the  limbs  move  by  volition.  For  a  month 
there  Avas  little  change.  Then  occurred  drowsiness,  and  increased  pros- 
tration, and  five  weeks  later  the  child  succumbed  Avith  the  symptoms  of 
double  pneumonia. 

Such  is  the  clinical  history  of  hypertrophy.  In  cases  of  firm  ossifica- 
tion of  the  cranial  bones,  and,  therefore,  no  marked  enlargenicnt  of  the 
skull,  the  symptoms  are  simdar  to  those  Avhich  occur  if  the  dimensions 
of  the  head  be  increased,  but  compression  and  death  result  sooner. 

The  following  case,  in  which  the  sutures  were  firmly  united,  I  attended 
in  18G4.  The  head  was  large,  but  not  so  large  as  to  attract  attention 
from  its  disproportion: 

Case. — A  boy,  aged  two  years  and  two  months,  had,  when  about  one 
year  old,  intermittent  fever,  and  since  then  his  countemuice  was  uniformly 
j)allid,  and  his  flesh  soft.  Weaned  at  the  usual  time,  he  remained  well 
till  the  1st  of  January,  1864.  In  the  beginning  of  this  month  he  was  ob- 
served to  be  feverish  for  some  days,  and  his  appetite  poor.  His  health 
then  gradually  improved,  and  he  was  thought  to  be  entirely  well. 

On  the  2(>th  of  February  he  was  suddenly  seized  with  convulsions,  gen- 
eral at  first,  but  most  severe  and  continuing  longest  on  the  left  side.  The 
convulsions  lasted  a  little  more  than  three  hours.  He  recovered  fully  his 
consciousness  by  the  following  day,  but  his  appetite  remained  poor;  he 
was  no  longer  annised  by  his  playthings,  and  was  very  fretful.  The  sur- 
face was  pallid;  bowels  constipated  ;  pulse  ])ut  little,  perhaps  not  at  all, 
accelenited.  He  continued  in  this  state  till  the  6th  of  INIareh,  when  he 
had  another  slight  convulsive  attack,  and  from  this  time  he  never  fully 


DIAGNOSIS.  423 

recovered  his  consciousness.  He  was  fretful  if  disturbed,  his  face  gener- 
ally j)allid,  while  the  pulse  and  respiration  were  not  perceptibly  altered. 

On  the  fjllowing  day,  the  7th,  the  left  pupil  was  somewhat  larger  than 
the  right,  but  both  were  sensitive  to  light.  The  difference  in  size  con- 
tinued till  near  the  close  of  life.  Altliough  vision  was  imperfect,  if  not 
altogether  lost,  the  sense  of  hearing  was  not  impaired. 

When  questioned,  he  uniformly  answered,  "  No,"  with  a  drawliug  voice, 
evidently  not  understanding  what  he  said. 

As  the  disease  advanced,  the  respiration  became  at  times  sighing ;  but 
the  rhythm  of  the  pulse  Avas  not  materially  altered.  The  temperature  of 
the  surface  was  changeable,  sometimes  cool,  sometimes  warm,  and  the  con- 
gested spots  or  patches,  so  common  in  cerebral  atiections,  were  also  ob- 
served at  times  on  the  face,  ears,  or  forehead.  Through  most  of  his  sick- 
ness he  took  drinks  readily,  and  the  urine  was  freely  discharged,  probably 
from  the  iodide  of  potassium,  which  he  took  in  one  and  a  lialf  grain  doses 
every  two  hours. 

He  l)ecame  more  and  more  drowsy,  again  had  slight  convulsive  move- 
ments, and  finally  died,  with  much  apjjarent  suffering,  on  the  14th  oi 
March.  The  pulse  became  more  accelerated  during  the  last  two  or  three 
days.  On  the  day  preceding  his  death,  the  pupils  were  contracted,  and 
not  affected  by  light. 

Sedio  Oidav. — Body  somewhat  emaciated,  and' eyes  sunken;  occipito- 
frontal circumference  of  head  nineteeu  and  a  half  inches ;  distance  from 
one  auditory  meatus  to  the  other  over  the  vertex,  thirteen  and  a  half 
inches;  convolutions  over  the  surface  of  the  brain  much  flattened  and 
compressed  ;  brain  generally  deficient  in  blood  ;  medullary  substance  firm, 
and  of  a  pure  white  color  ;  meninges  healthy  ;  no  other  abnormal  appear- 
ances were  observed  ;  weight  of  brain  forty-two  ounces. 

Diagnosis. — The  diagnosis  of  hypertro])liy  is  not  always  easy.  The 
symptoms  are,  in  the  main,  such  as  occur  in  other  pathological  states, 
especially  congenital  hydrocephalus.  There  is  most  danger  of  mistaking 
the  overgrowth  for  this  disease.  Hvpertrophj  has,  indeed,  often  been 
treated  for  liydrocephalus.  There  are,  however,  certain  signs  ])y  wliich 
we  may  distinguish  one  from  the  other.  In  the  ordinary  form  of  con- 
genital hydroco])halus,  even  when  the  amount  of  licfuid  is  small,  the 
orbital  plates  of  the  frontal  bones  are  pressed  in  such  a  way  that  the 
axis  of  the  eyes  is  changed  so  as  to  have  a  downward  direction.  The 
white  of  the  eye  can  be  seen  between  the  iris  and  the  up])er  eyelid. 
This  gives  a  characteristic  and  striking  expression  to  the  face.  The 
exception  to  this  is  in  those  rare  cases  in  which  the  liquid  is  externsU 
to  the  brain.  In  hypertrophy  this  peculiar  change  in  the  axis  of  the 
eyes  does  not  occur.  Moreover,  in  hypertrophy  there  is  not  that  uni- 
form expansion  of  the  liead  which  is  observed  in  hydrocephalus,  as  has 
been  stated  above.  There  are,  cotnmonly,  greater  enlargement,  more 
prominence  of  the  anterior  fontanelle,  and  Avidcr  sepanition  of  the  cra- 
nial bones,  in  liydrocephalus  than  in  hypertropliy.  But  since  in  some 
cases  of  hydrocephalus  the  sutures  are  united,  and  the  fontanelles 
closed,  and  there  is  no  change  in  the  direction  of  the  eyes,  the  reason 
of  tiic  dillicuhy  in  making  a  ])0sitive  differential  diagnosis  between 
tiuvse  two  diseases  in  certain  instances  is  ajiparent. 

Hypertrophy  with  consolidation  of  the  cranial  bones,  and,  therefore, 


424  THPOMBOSIS    IX    THE    CRANIAL    SINUSES. 

little  enlar<i;oment  of  the  head,  may  be  mistaken  for  meninojtis.  The 
history  of  the  case,  and  the  means  by  ■which  we  diagnosticate  the  latter 
affection,  which  will  be  described  in  their  proper  place,  will  usually 
enable  the  physician  to  make  a  correct  diagnosis. 

PrO(!XOSIS. — In  forming  an  opinion  as  to  the  probable  termination 
of  the  disease,  we  must  have  rei^ard  to  the  ao-e  and  jxeneral  condition  of 
tlie  child,  as  well  as  to  the  degree  of  hypertrophy.  If  the  disease  com- 
mence at  an  early  age,  when  the  cranial  bones  are  not  firmly  united,  it 
is  probable  that  there  will  be  no  compression  of  the  brain,  so  as  to 
endanger  life,  for  a  considei'able  period.  We  may  then  hope  by  proper 
measures  to  remove  the  constitutional  state  which  gives  rise  to  the 
hypertrojihy,  before  the  enlargement  is  such  as  to  cause  cerebral  symp- 
toms. If  the  bones  have  already  united  when  the  disease  commences, 
even  slight  hypertrophy  will  produce  symptoms,  and  a  speedily  fatal 
result  is  inevitable.  Evidently,  also,  a  child  in  a  marked  degree  rachitic 
or  scrofulous  is  much  less  likely  to  recover  than  one  whose  general 
health  and  constitution  are  less  impaired. 

Treatment. — The  treatment  in  hypertrophy  should  be  directed 
maiidy  to  the  constitution.  Measures  calculated  to  improve  the  nutri- 
tive process  are  those  most  likely  to  check  the  abnormal  growth  of  the 
brain.  As  the  disease  is  one  of  perverted  nutrition,  and  usually  coexists 
with  a  vitiated  or  impoverished  state  of  the  blood,  tonic  and  alterative 
remedies  are  required.  The  syrupus  ferri  iodidi  is,  therefore,  useful, 
as  it  is  both  tonic  and  alterative.  This  may  be  given  in  doses  of  three 
or  four  drops  to  a  child  one  year  old,  three  times  daily.  Cod-liver  oil, 
with  or  without  the  iron,  is  beneficial  in  some  cases.  Another  remedy 
is  iodide  of  potassium  in  combination  with  a  tonic,  as  the  compound 
tincture  of  bark. 

R. — Potass,  iodic!. 3;j. 

Tinct.  cinchon.  comp., 

Syr.  Hmon.     ........  an  _^ij. — ^lisce. 

One  teuspoonful,  three  limes  daily,  to  a  child  of  three  years. 

The  hygienic  treatment  is  not  less  important  than  the  medicinal. 
There  is  little  hope  of  a  favorable  issue  in  any  case,  unless  the  regimen 
be  sucii  as  will  conduce  to  a  more  robust  and  healthy  state  of  system. 
The  diet  should  be  plain  and  nutritious,  the  apartments  clean  and  airy, 
and  all  undue  excitement  should  be  avoided. 


CHAPTER  lY. 

THROMBOSIS  IN  THE  CRANIAL  SINUSES  (PHLEBITIS). 

The  formation  of  fibrinous  coagula  within  a  vein  or  sinus  is  desig- 
nated thrombosis  (thromlniH,  clot).  Coagulation  of  fibrin  in  the  cranial 
sinuses  occasionally  occurs,  constituting  a  very  serious  ])atliological  state. 
This  may  result  from  local  disease  in  the  sinuses  or  in  their  vicinity,  or 


AXATOMIC.iL    CHARACTERS  425 

from  disease  external  to  the  cranium.  The  immediate  cause  of  throm- 
bosis, Avhatever  its  location,  is  sufficient  arrest  of  the  circulation  to  allow 
the  fibrin  to  coagulate. 

Tubercular  and  enlarged  bronchial  glands,  compressing  more  or  less 
the  venge  innominata,  or  the  descending  vena  cava,  sometimes  give  rise 
to  thrombosis  in  the  cranial  sinuses,  the  fibrin  coagulating  in  conse- 
quence of  retardation  in  the  current  of  blood.  I  have  known  throm- 
bosis, in  the  same  situation,  also  to  result  from  clonic  convulsions,  occur- 
ring in  connection  ■svith  severe  spasmodic  cough  in  pertussis,  since  both 
ti»e  cough  and  convulsions  retard  the  flow  of  blood  in  the  veins  and 
sinuses  within  the  cranium.  At  the  post-mortem  examination  of  at  least 
four  such  cases  I  found  whitish  clots  in  the  lateral  sinuses. 

Thrombosis,  in  the  cranial  sinuses,  may  also  occur  from  inflammation, 
eitlier  in  the  walls  of  the  sinuses  or  immediately  exterior  to  them.  This 
is  tiie  disease  which  writers  have  designated  phlebitis  of  the  cranial 
sinuses,  and  for  a  correct  understanding  of  the  morbid  anatomy  of  which 
the  profession  are  indebted  to  Virchow. 

AxATOMiCAL  Characters. — If  a  child  die  with  the  cranial  sinuses 
and  the  veins  of  the  brain  and  of  the  meninges  in  their  normal  state, 
tlie  bioo<l  in  these  vessels  is  found  at  the  autopsy  dark  but  liquid,  or 
there  are  small,  dark,  and  soft  clots  in  the  larger  sinuses.  If  there  were 
congestion,  but  no  coagulation,  in  these  vessels  in  the  last  hours  of  life, 
the  clots  are  more  numerous,  larger,  and  longer,  sometimes  extending 
from  the  sinuses  into  the  larger  veins  which  empty  into  them,  but  they 
are  still  dark  ami  soft,  readily  falling  to  pieces  when  handled.  If, 
again,  there  have  been  that  degree  ot  congestion  and  stasis  which  has 
resulted  in  ante-mortem  coagulation,  or  in  thrombosis,  the  clots  are,  in 
part  at  least,  whitish,  and  of  a  fibrinous  or  gelatinous  appearance  ;  they 
were  formed  while  the  red  corpuscles  were  still  carried  along  in  the 
circulation. 

Most  of  the  clots  in  thrombosis  are  free,  while  others  are  attached 
lightly  to  tJie  internal  surface  of  the  sinus ;  occasionally  they  are  so 
large  as  to  disteml  the  vessel.  They  extend  also  in  many  cases  into  the 
cerebral  veins  which  connect  with  the  sinuses,  producing  prominence 
and  firmness,  so  as  to  resemble  (Rilliet  and  Barthez)  an  artificial  injec- 
ti(m.  The  clots  do  not  present  a  uniform  character.  In  ))arts  of  a 
sinus  they  consist  of  almost  pure  fibrin,  of  a  yellowish-white  color,  while 
in  other  portions  they  present  a  gelatinous  appearance  from  the  large 
number  of  white  corpuscles,  while  other  portions  are  more  or  less  tinged 
from  the  presence  of  red  corpuscles.  The  central  part  of  the  clot,  after 
a  time,  if  the  case  be  sufficiently  protracted,  softens,  and  presents  a  puri- 
f  >rui  apj)earance.  This  substance,  which  is  only  disintegrated  fibrin, 
w;is  supposed  to  be  j)us,  till  the  microscope  revealed  its  true  character. 
It  is  obvious  that  small  clots  forming  within  a  sinus,  and  having  no 
attachment  to  its  walls,  are  liable  to  be  carried  by  the  current  of  blood 
into  the  general  circulation,  unless  there  be  complete  obstruction. 
Virchow  has  also  shown  how  a  thrombus  may  extend,  by  gradual  pro- 
loiigiition.  nearer  and  nearer  the  heart,  so  that  one  comuieiicing  in  a 
sinus  may,  after  a  tiiiif.  reach  into  the  juLrnlir  vein.  DitVcrcnt  ob- 
servers, as  M.  Tonnele,  and  aLso  liilliet  and  Hdvilmz,  have  traced  the 


426  THEOMBOSIS    IN    THE    CRAXIAL    SINUSES. 

fibrinous  masses  as  flir  as  the  cava.  The  latter  writers  relate  the  case 
of  a  girl,  four  and  a  half  years  old,  in  whom  the  sinuses  on  the  left  side, 
especially  those  nearest  the  petrous  portion  of  the  temporal  bone,  were 
completely  filled  Avith  clots  of  a  yellowish-white  color,  intermixed  with 
central  dark  spots.  Similar  coagula  were  also  found  in  the  left  jugular 
vein  as  far  as  the  brachio-cephalic  trunk.  Whether  the  walls  of  the 
sinus  undergo  any  change  depends  on  tlie  nature  of  the  disease  which 
causes  the  thrombosis,  if  it  be  phlebitis,  the  coats  are  thickened  from 
infiltration  and  injected,  and  the  internal  coat  has  lost  its  polish.  If  it 
be  some  obstructive  disease  in  the  course  of  the  circulation,  or  a  general 
cause,  the  coats  of  the  vessel  are  unaltered,  except  that  they  may  be 
stained  by  im])ibition  of  the  coloring  matter  of  the  blood.  In  an  infant 
who  died  of  this  disease  in  the  practice  of  Dr.  West,  "  the  sinuses  on  the 
left  side  were  healthy,  but  the  blood  was  almost  entirely  coagulated. 
The  posterior  half  of  the  longitudinal  sinus,  the  torcular,  the  left  lateral, 
and  the  left  occipital  sinuses,  were  blocked  up  with  fibrinous  coagula, 
precisely  such  as  one  sees  in  inflamed  veins,  and  the  clot  extended  into 
the  internal  jugular  vein.  The  coats  of  the  longitudinal,  and  of  the  inner 
half  of  the  lateral  sinus,  were  much  thickened,  and  their  lining  mem- 
brane had  lost  its  polish,  Avas  uneven,  and  ])resented  a  d'lvty  apjjearance." 

The  mode  in  which  congestion  and  coagulation  occur  Avithin  a  sinus, 
in  consequence  of  the  pressure  of  a  tumor  upon  this  vessel,  or  upon  a 
vein  into  Avhich  the  blood  from  this  sinus  floAvs,  is  sufficiently  obAaous. 
The  mode  of  the  production  of  thrombosis,  as  a  result  of  clonic  convul- 
sions, or  of  the  spasmodic  cough  of  pertussis,  is  also  apparent.  Hoav  it 
results  from  inflammation  of  the  Avails  of  a  sinus,  that  is,  from  phlebitis, 
was  not  understood  till  explained  ])y  Virchow. 

The  fibrinous  coagula  which  fill  the  sinus  are  not  an  exudative  pro- 
duct, as  was  formerly  supposed.  Inflammation  (in  most  cases  otitis, 
Avitli  caries  of  tlie  petrous  portion  of  the  temporal  bone)  approaches  a 
sinus.  The  inflammatory  products  })ressing  against  the  Avails  of  the 
sinus  diminish  its  calibre  at  that  point,  and  hence  the  retardation  of 
blood  aiul  tiie  coagulation.  Or  the  Avails  of  the  sinus  may  be  thickened 
by  inflammatory  infiltration,  or  even  by  the  formation  of  little  abscesses 
Avithin  the  coats  in  consequence  of  the  inflammation,  so  as  to  produce 
bulging  inAvard,  and  the  result,  as  regards  the  circulation,  is  the  same. 
Whether,  therefore,  the  inflammation  occur  Avithout  a  sinus,  or  Avithin 
its  Avails,  thrombosis  e(iually  results,  provided  that  the  diameter  of  the 
vessel  is  sufficiently  narrowed  by  the  presence  and  pressure  of  inflam- 
matory products. 

There  is  no  exudation  on  the  internal  surface  of  a  sinus  or  A'ein  when 
inflamed,  as  there  is  upon  serous  surfaces.  "On  the  contrary' when 
the  Avail  is  inflamed,  the  exuded  matter  (exsudatmasse)  passes  into  the 
Avail,  Avliich  becomes  thicker,  cloudy,  and  subse(|uently  l)egins  to  sup- 
purate. Niiy,  even  abscesses  may  form  Avhich  cause  the  wall  to  bulge 
on  both  sides  like  a  variolous  pustule,  Avithout  any  coagulation  of  the 
blood  ensuing  in  the  cavity  of  the  vessel.  At  other  times,  certainly, 
phlebitis,  properly  so  called  (and  in  like  manner  arteritis  and  endocar- 

1  Cellular  Palliology,  translatiun,  p.  236. 


SYMPTOMS.  427 

ditis),  is  the  cause  of  thrombosis,  in  consequence  of  the  formation  of  in- 
equalities, elevations,  depressions,  and  even  ulcerations  u])on  the  inner 
•v\all  -which  favor  the  production  of  the  thrombus.  Still,  whenever  phle- 
bitis, in  the  usual  sense  of  the  word,  takes  place,  the  alteration  in  the 
coat  of  the  vessel  is  almost  always  a  secondary  one,  and,  indeed,  occurs 
at  a  comparatively  late  period." 

This  view  of  the  pathology  of  thrombosis  comports  with  facts  observed 
at  autopsies,  and  which  camiot  be  explained  according  to  the  old  theory 
of  phlebitis,  namely,  smoothness  of  the  internal  surface  of  the  sinus; 
natural  color  of  this  sinus,  or  simple  staining  from  blood;  the  non- 
attachment  or  slight  attachment  of  the  coagula,  etc. 

Causes. — Some  of  these  have  been  already  stated  at  the  commence- 
ment of  this  article.  It  is  evident  from  what  has  been  said  that  this 
disease  may  be  produced  by  any  cause  Avhich  obstructs  the  return  circu- 
lation from  the  head.  I  have  alread}'^  alluded  to  tumors  which  press 
upon  the  sinus,  or  on  the  vein  below  the  sinus,  as  a  cause.  Among  the 
causes  may  be  mentioned  also  abdominal  tumors,  narrowing  of  the  chest 
from  rachitis,  or  caries  of  the  vertebrae,  and,  finally,  compression  of  the 
jugular  vein  by  a  peri})haryngeal  abscess. 

Sufficient  allusion  has  already  been  made  to  inflammation  of  the  in- 
ternal ear  as  a  not  infrequent  cause.  Thrombosis  is,  indeed,  one  of  the 
dangerous  results  of  chronic  otitis.  Another  cause  is  a  reduced  or 
cachectic  state  of  system,  apart  from  any  local  or  obstructive  disease. 
It  is  a  noteworthy  fact  that  a  large  proportion  of  those  affected  with 
throudjosis,  even  Avhcn  it  is  immediately  due  to  obstructive  disease,  are 
cachectic.  The  exqjhination  of  this  fict  is  not  difficult.  In  reduced 
states  of  the  s^'stem  the  acti(tn  of  the  heart  is  feeble,  and  passive  conges- 
tion of  the  vessels  within  the  cranium  is  liable  to  occur.  Passive  con- 
gestion of  the  veins  and  sinuses  in  protracted  diarrlueal  maladies,  which 
is  described  in  our  remarks  upon  another  disease,  is  an  example  in  point. 
In  this  state  of  feel)le  circidation  very  slight  obstructive  disease  may  be 
sufficient  to  cause  thrombosis. 

Symptoms. — The  symptoms  of  this  disease  are  often  obscure.  All 
of  them  may  and  do  occur  in  other  maladies  of  the  encephalon.  In 
cases  related  by  M.  Tonnele,  cerebral  symptoms  were  well  marked,  such 
as  faintness,  dilatation  of  the  pupils,  strabismus,  grinding  of  the  teeth, 
convulsive  movements.  There  may  be  an  almost  total  absence  of  such 
syni])tftms  as  would  direct  attention  to  the  state  of  the  head.  This  is 
due  to  the  sudden  occurrence  of  death  after  the  clots  have  formed  in  the 
sinuses.  If  the  clots  are  large,  death  soon  results  in  consetiuence  of  con- 
gestion of  the  brain  and  meninges,  which  is  proportionate  to  the  amount 
of  ol)stnK-tion.  Extravasations  of  blood  and  transudation  of  serum  not 
infrequently  accompany  the  congestion  and  liasten  the  result. 

Dr.  West  relates  the  case  of  a  girl  who  had  a  mild  attack  of  scarlet 
fever  at  the  age  of  eight  months,  and  did  not  fully  recover  her  health. 
She  continued  restless  and  feverish,  and  had  two  violent  convulsions 
two  weeks  after  the  scarlatina.  In  tiie  following  months  she  had  ana- 
sarca, and  when  she  was  nearly  a  year  old  another  attack  of  convulsions 
occurre<l.  Fluctuation  was  now  observed  in  the  abdomen,  and  in  a  few 
days  a  sero-purulent  fluid  began  to  escape  from  the  umbilicus.     When 


428  THROMBOSIS    IX    THE    CRANIAL    SINUSES. 

this  discliarge  had  continued  eleven  days,  symptoms  of  a  hquid  in  the 
right  pleural  cavity  were  suddeidy  developed.  She  grew  weak  and 
emaciated,  and  finally  was  seized  with  extreme  faintness,  with  which  she 
died  in  forty-eight  hours,  at  the  age  of  thirteen  and  a  half  months. 

At  the  post-mortem  examination  a  large  amount  of  pus  was  found  in 
the  abdominal  and  right  pleural  cavities.  On  the  right  side  of  the 
cranium,  the  sinuses  were  filled  with  coagula,  and  their  coats  seemed 
healthy.  The  left  lateral  and  occipital  sinuses,  the  torcular  and  part  of 
the  longitudinal  sinus,  also  contained  coagula,  which  extended  into  the 
jugular  vein.  The  walls  of  the  longitudinal  sinus  and  the  internal  part 
of  the  lateral  sinus  were  thickened,  and  their  inner  surface  had  lost  its 
polish  and  was  uneven.  There  was  congestion  of  the  brain,  with  points 
of  extravasated  blood.  If,  as  is  probable,  the  convulsions  were  due  to 
some  other  cause,  the  only  symptom  which  was  clearly  referable  to  the 
thrombosis  was  the  sudden  fointness.  In  the  four  CciSes  of  thrombosis 
occurring  in  pertussis,  already  alluded  to,  in  which  I  was  enabled  to 
ascertain  by  post-mortem  examination  the  presence  and  extent  of  the 
clots,  the  symptoms,  which  Avere  apparently  due  to  the  thrombosis,  were 
those  of  cerebral  congestion.  Among  these  symptoms,  stupor,  and 
finally  coma  were  prominent.  The  convulsions  which  occurred  in  both 
cases  were  apparently  a  cause,  and  not  a  result,  of  the  thrombosis. 

Diagnosis. — It  is  evident,  from  what  has  been  said,  that  thrombosis 
of  the  cranial  sinuses  can  rarely  be  diagnosticated  with  certainty.  The 
preexistence  of  otitis  will  sometimes  lead  us  to  suspect  its  presence, 
especially  if  the  otitis  have  been  accompanied  by  deep-seated  pains. 
Symptoms  of  cerebral  congestion,  serous  effusion,  or  apoplexy,  occur- 
ring in  connection  with  otitis,  protracted  convulsions,  or  glaiulular  or 
other  tumors  situated  so  as  to  compress  the  vessels  Avhich  return  blood 
from  the  brain,  indicate  thrombosis. 

Prognosis. — The  prognosis,  in  any  case,  is  obviously  unfavorable. 
The  cause  is,  ordinarily,  permanent,  or  not  readily  removed,  so  that 
the  clots  gradually  increase.  If  the  cause  be  a  local  obstructive  disease, 
death  is  almost  certain,  since,  in  nearly  every  instance,  the  obstruction 
is  of  such  a  nature  that  it  cannot  be  removed  by  medical  or  surgical 
treatment.  It  is  possible  that  recovery  may  take  ])lace  if  the  clots  are 
few  and  small,  and  the  cause  of  the  thrombosis  be  mainly  feebleness  of 
circulation  in  consequence  of  a  state  of  debility.  AVe  know  that  dots 
may  liquefy,  and  their  elements  reenter  the  circulation ;  but  such  a 
result  of  thrombosis  in  a  cranial  sinus,  if  it  over  occur,  is  rare.  The 
thrombus,  by  its  presence,  serves  as  a  point  of  attachment  around  which 
more  fibrin  coagulates,  so  that  the  obstruction  gradually  increases  till 
death  occurs. 

Treatment. — Thrombosis  should  be  treated  by  cool  applications  to 
the  head,  in  order  to  diminish  the  congestion,  by  stimulants  and  sustain- 
ing measures  in  case  the  systolic  movement  of  the  heart  l)e  feel)le.  Tonics, 
vegetable  or  ferruginous,  are  indicated  if  there  be  a  cachectic  state. 


CONQESTION    OF    THE    BRAIN.  429 


CHAPTER    Y. 

COXGESTIOX  OF  THE  BRAIN. 

Congestion  of  the  brain  is  not  peculiar  to  infancy  and  childhood, 
but  is  much  more  common  in  these  periods  of  life  than  subsequently. 
This  is  due,  in  a  great  measure,  to  the  fact  that  in  the  young  the  circu- 
lation is  more  readily  disturbed  by  moral  as  Avell  as  physical  causes 
than  in  the  adult. 

Congestion  of  the  brain  is  occasionally  primary  ;  more  frequently  it 
occurs  as  a  concomitant  or  sequel  of  some  other  aifection.  Diseases, 
whether  constitutional  or  local,  which  in  the  adult  have  no  appreciable 
eifect  on  the  vascularity  of  the  brain,  often  cause  in  the  child  a  decided 
increase  of  blood  in  this  organ. 

Causes. — Cerebral  congestion  is  of  two  kinds,  active  and  passive. 
The  former  results  from  a  cause  which  directly  aifects  the  brain,  and 
increases  the  flow  of  blood  toward  it,  or  from  a  cause  operating  prim- 
arily on  the  heart,  and  increasing  the  frequency  and  force  of  its  s\^stolic 
movement ;  the  latter  is  due  to  some  obstruction  in  the  course  of  the 
circuhition,  or  to  feeble  propelling  power  on  the  part  of  the  heart. 

Among  the  causes  which  most  frecjuently  produce  active  congestion 
of  the  brain  in  the  child,  may  be  mentioned  blows  or  falls  on  the  head, 
excessive  fatigue  or  excitement,  heat,  perhaps  sometimes  dentition,  and 
also  various  inflammatory  and  febrile  affections,  especially  in  their  first 
stages. 

Cerebral  symptoms  occurring  in  the  course  of  an  essential  fever  are 
no  doubt  often  due,  in  a  great  measure,  to  the  irritating  effect  on  the 
brain  of  the  specific  principle,  whatever  it  may  be,  circulating  in  the 
blood.  Occurring  in  inflammatory  diseases  which  are  located  elsewhere 
than  within  the  craniuui,  they  are  often  attributed  to  functional  disturb- 
ance of  the  brain.  The  brain,  it  is  said,  sympathizes  with  the  alfccted 
part  through  the  system  of  nerves  which  unite  them.  But  observations 
show  that  symptoms  referable  to  tlie  brain,  arising  in  the  commencement 
of  the  essential  fevers  and  of  the  phlegmasia,  are  in  many  instances  pre- 
ceded by,  and  are  tlierefore,  doubtless,  in  greater  or  less  degree  depen- 
dent on,  hyp'jr;cmia  of  this  organ. 

Difficult  as  it  is  to  ascertain  the  state  of  the  brain  in  many  diseases 
in  which  it  is  involved,  we  may  determine  whether  or  not  there  be  con- 
gestion in  the  young  child  by  observing  the  anterior  fontanelle.  If  it 
be  elevated  and  tense  in  an  acute  disease,  hypencmia  is  indicated.  Now, 
it  is  often  unusually  prominent  in  fevers  and  inflammations,  especially 
in  their  first  stages,  when  cerebral  symptoms  are  present.  Its  elevation, 
under  such  circumstances,  is  obviously  coincident  with  cerel)ral  con- 
gestion. 

The  acute  inflammations   whicli  arc  most  likely  to  be  attended  by 


430  CONGESTION    OF    THE    BRAIN. 

cerebral  congestion  arc  those  of  the  mucous  surfaces  and  pneumonia. 
Severe  coryza,  tracheo-bronchitis,  entero-colitis,  and  colitis,  commencing 
suddenly  with  great  febrile  excitement,  are  frequently  accompanied  in 
their  initial  stage  by  active  congestion  of  the  cerebral  vessels.  Cases 
like  the  following,  "which  I  find  in  my  note-book,  are  not  infrequent. 
An  infant  four  months  old  had  been  sick  about  two  days  with  coryza 
and  bronchitis,  when  I  was  called  to  see  it;  the  pulse  numbered  15G  ; 
respiration  64;  it  nursed,  and  was  somewhat  restless;  cough  frequent 
and  dry;  boAvels  moderately  relaxed.  The  mucous  membrane  of  the 
fauces  was  injected,  and  coarse  mucous  rales  were  present  in  the  chest. 
The  anterior  fontanelle  rose  above  the  level  of  the  cranium,  and  pul- 
sated forciljly.  Soon  after  convulsions  occurred,  which  Avere  relieved 
by  appropriate  measures,  and  on  the  following  day  the  fontanelle  had 
subsided.  The  patient  gradually  recovered  without  any  untoward 
symptom. 

Cerebral  congestion  and  convulsions  often  mark  the  initial  stage  of 
active  intestinal  phlegmasi;ie.  This  is  especially  true  of  dysentery. 
The  little  patient,  perhaps  from  the  very  inception  of  the  colitis,  is 
drow\sy ;  its  surface  hot ;  pulse  full  and  rapid.  There  is  sudden  and 
momentary  starting  or  twitching  of  the  limbs.  The  anterior  fontanelle, 
if  still  open,  is  elevated,  and  it  is  not  till  the  lapse  of  several  hours  that 
the  cause  of  these  symptoms  is  apparent  from  the  occurrence  of  bloody 
stools. 

The  causes  of  passive  congestion  of  the  brain  are  very  different  from 
those  of  the  active  form.  A  common  cause  is  obstruction  in  a  sinus  or 
vein  by  a  fibrinous  concretion,  or  by  a  tumor  or  abscess  external  to  it. 

I  have  occasionally  met  cases  in  Avhich  this  form  of  cerebral  conges- 
tion appeared  to  be  plainly  referable  to  obstruction  to  the  return  of 
blood  from  the  brain  by  the  pressure  of  bronchial  glands,  enlarged  by 
hyperplasia  in  tubercular  disease,  these  bodies  diminishing  by  external 
pressure  the  calibre  of  the  venae  innominatce  or  the  descending  vena 
cava.  Rilliet  and  Barthez  have  called  attention  to  such  cases  in  the 
clinical  history  of  tuberculosis.  The  following  case  may  be  cited  as  an 
example ;  it  occurred  in  the  infants'  service  of  Charity  Hospital,  in  this 
city,  in  April,  1866. 

An  infant,  about  one  year  old,  affected  with  tuberculosis,  both  bron- 
chial and  pulmonary,  was  observed,  during  the  ten  days  preceding  its 
death,  to  bore  the  pillow  with  its  head  almost  constantly,  so  as  to  wear 
the  hair  from  the  occiput.  This  movement  of  the  head  was  the  only 
prominent  cerebral  symptom.  Nothing  abnormal  was  noticed  in  the 
appearance  of  the  eyes,  nor  was  the  stomach  irritable.  A  spasmodic 
cough  and  progressive  emaciation  attracted  attention,  but  these  were 
referable  to  the  tubercular  disease.  At  the  autopsy  we  found  the 
cerebral  sinuses,  veins,  and  capillaries  greatly  congested.  On  tracing 
the  veins  which  return  blood  from  the  brain,  an  inflamed  and  enlarged 
bronchial  gland  was  discovered  in  the  angle  formed  by  the  convergence 
of  the  right  and  left  ven;ie  innominatce.  This  gland,  which  contained 
but  a  single  point  of  cheesy  degeneration,  harl  attained  such  a  volume 
by  proliferation  of  its  cells  that  it  pressed  upon  both  vessels,  so  that  it 


AXATOMICAL    CHARACTERS.  431 

had  obviously  retarded  the  circulation  in  each,  and  given  rise  to  cere- 
bral congestion. 

Passive  congestion  often  occurs  in  the  infant  at  birth,  either  from 
tediousness  of  the  labor  or  delay  in  the  expulsion  of  the  body  after  the 
birth  of  the  head.  If  it  be  simple  congestion,  and  not  congestion  -with 
hemorrhage,  it  soon  passes  off.  Passive  congestion  of  the  brain  also 
occurs  in  severe  paroxysms  of  hooping-cough,  in  Avhich  return  of  blood 
from  this  organ  is  temporarily  retarded.  All  are  familiar  -with  the  con- 
gestion which  occurs  in  parts  external  to  the  cranium,  from  the  severity 
of  the  cough ;  producing  epistaxis,  extravasations  under  the  conjunc- 
tiva, etc.  The  extra-cranial  obviously  indicates  the  presence  and  degree 
of  cerebral  congestion. 

Those  who  practise  in  malarious  regions  sometimes  meet  cases  of  dan- 
gerous passive  congestion  of  tlie  brain,  the  result  of  malaria,  occurring 
especially  in  the  cold  state  of  intermittent  fever.  In  these  cases  the 
surface  is  pallid,  its  temperature  reduced,  and  the  pulse  feeble.  The 
blood,  leaving  the  peripheral  vessels,  collects  in  undue  quantity  in  the 
internal  organs,  producing  congestion  of  the  brain,  as  well  as  of  the 
thoracic  and  abdominal  viscera.  In  the  child  Avith  malarial  disease,  in 
whom  there  is  less  vigor  of  constitution  than 'in  the  adult,  death  not 
infrequently  occurs  in  this  passive  congestion.  Two  such  cases  have 
occurred  in  my  practice,  although  in  this  latitude  the  malarial  maladies 
are  mild  in  comparison  with  the  type  Avhich  they  present  in  many  parts 
of  tlic  United  States. 

Symptoms. — Tlic  symptoms  of  active  congestion  of  the  brain  are 
stupor,  great  heat  of  head,  throbbing  of  carotids,  restlessness  when 
aroused,  twitching  of  the  limbs,  and  perhaps  convulsions.  There  is 
also  sometimes  intolerance  of  light,  and  the  anterior  fontanelle,  if  open, 
pulsates  strongly.  In  passive  congestion  many  of  the  symptoms  are 
the  same  as  in  the  active  form.  Stupor,  twitching  of  the  limbs,  and 
fretfulness  or  irritability  when  the  patient  is  disturbed,  are  common, 
ordinarily  without  increase  of  temperature ;  the  surface  may,  indeed, 
be  cool,  and  the  foce  is  not  flushed,  nor  the  eyes  injected.  The  strong 
pulsation  and  elevation  of  the  anterior  fontanelle,  so  conspicuous  in 
active  congestion,  are — the  former  always,  the  latter  often — lacking. 
In  both  forms  there  is  tendency  to  constipation. 

In  many  cases  the  symptoms  of  congestion  of  the  brain  are  associated 
with  others  which  proceed  directly  from  the  cause  of  the  congestion, 
but  it  is  not  difficult,  unless  in  exceptional  instances,  to  determine 
which  are  due  to  the  congestion,  and  which  to  the  antecedent  and 
coexisting  pathological  state. 

Anatomical  Characters. — In  active  congestion  there  is  an  excess 
of  arterial  blood  in  the  brain  and  its  membranes.  The  arteries,  to  their 
minutest  branches,  are  seen  to  be  full,  presenting  the  bright  hue  of 
oxygenated  blood.  In  passive  congestion  the  sinuses  and  veins  are 
distended.  The  pia  mater,  choroid  plexus,  and  the  vessels  of  the  brain, 
have  a  darker  appearance  than  in  active  congestion.  In  both  forms  of 
congestion,  if  they  continue  for  a  little  time,  other  anatomical  changes 
occur.  If  there  be  great  distention  of  the  (';i])illaries,  these  vessels  are 
liable  to  give  way,  and  we  find  here  and  there  little  patches  of  extrava- 


432  CONGESTION    OF    THE    BRAIN. 

sated  blood.  In  other  cases  the  over-distention  is  relieved  by  the  tran- 
sudation of  the  serous  portion  of  the  blood  through  the  coats  of  the 
vessels.  The  cephalo-rachidian  fluid  is  then  found  in  excess  external 
to  the  brain  and  in  the  ventricles. 

Prognosis. — The  duration  and  the  result  of  congestion  of  the  brain 
depend,  in  great  measure,  on  the  nature  of  the  cause.  If  the  cause  be 
trivial,  as  mental  excitement,  fatigue,  exposure  to  heat,  there  is  usually 
prompt  relief  if  the  condition  of  the  patient  be  understood  and  properly 
treated.  If  the  cause  be  general  or  constitutional,  us  one  of  the  essen- 
tial fevers  or  hooping-cough,  or  if  it  be  local,  but  its  seat  external  to  the 
cranium,  the  prognosis,  so  far  as  the  congestion  is  concerned,  is  not 
unfavorable,  if  there  be  a  timely  and  judicious  use  of  remedies.  The 
most  unfavorable  cases  are  those  in  which  the  cause  is  seated  in  the 
encephalon,  and  those  in  which  there  is  some  obstructive  disease  in  the 
course  of  the  circulation.  Congestion  occurring  from  a  structural 
change  within  the  cranium  is,  from  the  nature  of  the  cause,  without 
remedy,  and  ordinarily  fatal.  Obstructive  diseases  of  the  circulatory 
system,  wherever  located,  being  for  the  most  part  permanent,  give  rise, 
as  a  rule,  to  incurable  congestion. 

Congestion  of  the  brain,  if  it  be  not  relieved  in  a  few  hours,  becomes 
less  and  less  amenable  to  treatment.  It  soon  passes  beyond  the  re- 
sources of  our  art,  and  ends  in  coma;  it  is  seldom  protracted  beyond  a  few 
days.  Extravasations  of  blood,  common  in  active  congestion,  and  serous 
eft'usion,  common  in  the  passive  form,  diminish  the  chances  of  a  favorable 
result. 

Treatment. — The  indication  for  treatment  in  active  congestion  is 
j)lain.  Measures  should  be  employed  which  produce  derivation  from 
the  brain.  Unless  there  l)e  an  asthenic  primary  affection,  in  the  course 
of  which  the  congestion  is  developed,  active  purgation  is  required.  A 
saline  purgative  is  ordinarily  preferable.  If  the  stomach  be  irritable, 
there  is  no  better  purgative  than  calomel.  In  all  cases  of  active  con- 
gestion, Avhatever  the  cause,  the  bowels  should  be  kept  open.  It  is  often 
better  not  to  wait  for  the  tardy  action  of  a  cathartic,  but  to  give  at  once 
an  enema  of  soap  and  water  or  salt  and  water.  External  derivative 
agents  are  also  indicated.  A  warm  mustard  foot-bath,  sinapisms  to  the 
back  of  the  neck  or  chest,  and  to  the  feet,  and  cold  applications  to  the 
head,  are  measures  which  should  never  be  neglected.  In  many  cases 
those  medicines  are  useful  which  reduce  the  contractile  power  of  the 
heart,  as  aconite. 

This  treatment,  if  employed  early,  Avill  relieve  the  congestion  in  a 
large  proportion  of  cases;  but  if  there  be  no  improvement,  if  the  child 
be  robust,  and  if  the  primary  affection  be  such  as  does  not  contraindicate 
loss  of  blood,  leeches  should  be  applied  to  the  temples  or  some  part  of 
the  head.  If  after  tlie  lapse  of  some  hours  cerebral  symptoms  continue, 
apoplexy  or  serous  effusion  has  probaldy  occurred.  Congestion  is  then 
no  longer  the  prominent  lesion,  and  it  is  proper  to  designate  the  disease 
by  another  name. 

The  treatment  appropriate  for  passive  congestion  is  somewhat  differ- 
ent; cold  applications  to  the  head,  and  those  of  a  derivative  nature  to 
the  extremities,  are  useful.     As  this  form  of  the  disease  is  not  primary, 


INTRACPwAXIAL    HEMORRHAGE.  433 

but  is  dependent  on  some  antecedent  pathological  state,  it  is  evident  that 
it  can  only  bo  treated  successfully  by  removing  or  obviating  the  cause 
so  far  as  possible.  But  the  nature  of  the  various  obstructions  to  the 
intracranial  circulation  is  such  that  our  ability  to  accomplish  this  end  is 
very  limited. 

If  the  cause  be  constitutional,  or  if  it  be  some  disease  in  the  neck  or 
chest,  it  may  sometimes  be  partially  or  even  wholly  removed,  but  if 
seated  -within  the  cranium  it  is  beyond  our  control.  In  general,  it  may 
be  said  that  depletion  is  not  required  or  tolerated  in  passive  congestion, 
and  stimulants  are  often  needed. 


CHAPTER  YI. 

INTRACRANIAL  HE:\rORRHAGE  (MENINGEAL  HEMORRHAGE. 
CEREBRAL  HEMORRHAGE). 

Hemorrhage  within  the  cranium  is  not  very  infrequent  in  infancy 
and  childhood;  and  there  is  no  part  of  the  encephalon,  whether  the 
meninges  or  brain,  in  which  it  does  not  sometimes  occur.  If  the  blood 
be  extra vasa ted  upon  the  surface  of  the  brain  or  between  the  meninges, 
the  disease  is  designated  by  writers  meningeal  apoplexy ;  if  in  the  sub- 
stance of  the  brain,  cerebral  apoplexy.  Extravasation  may  also  occur 
in  one  of  the  lateral  ventricles.  This  may,  for  convenience,  be  described 
as  a  form  of  meningeal  apoplex}'. 

Causes. — Apoplexy  is  usually  (there  is  an  exception)  preceded  by 
congestion.  If  the  congestion  increase  to  a  certain  degree,  the  distended 
capillaries  give  way  and  extravasation  of  blood  results.  Therefore  the 
causes  of  congestion  which  have  been  enumerated  in  the  preceding  article 
are,  in  great  mc;isure,  those  of  apoplexy.  Recent  microscopic  examina- 
tions have  demonstrated  that  the  corpuscular  elements  of  tiie  blood  may 
escajie  from  capillaries  without  rupture.  While,  therefore,  it  is  prob- 
able that  intracranial  hemorrhage  in  early  life  commonly  occurs  from  a 
rupture,  its  occasional  occurrence  through  the  walls  of  the  capillaries 
must  be  admitted. 

Intracranial  hemorrhage  is  not  infrequent  in  the  new])orn.  It  results 
in  them  from  tediousness  of  the  birth  and  severity  of  the  labor-pains. 
At  first  there  is  extreme  conijestion  of  the  menin!i;eal  an<l  cerebral  ves- 
sels  corresponding  with  that  of  the  scalp  and  face.  This  congestion, 
continuing,  soon  ends  in  extravasation  of  blood.  In  some  of  these  cases 
forceps  have  been  used  to  effect  the  delivery,  but  it  is  doubtful  whether 
the  use  of  instruments  materially  increases  the  congestion  or  tlie  amount 
of  extravasation.  Ortaiidy,  in  a  large  proportion  of  intracranial  as 
Well  as  supracranial  hemorrhages  of  the  newborn,  instruments  have  not 
been  used.  An  additional  cause  of  the  hemorrhajje  is,  in  some  instances, 
the  use  of  ergot,  which,  by  producing  strong  and   continuous  pains, 

28 


434  INTRACRANIAL    HEMORRHAGE. 

interrupts  the  placental  circulation  and  increases  the  congestion  of  the 

foetal  veins  and  capillaries. 

In  infants  a  few  days  old  intracranial   hemorrhage  may  result  from 

that  rai>id  and  fatal   disease,  tetanus  infantum.      The  iiemorrhaofe  is 

*  ,  ...  .  ^ 

preceded  by  intense  passive  congestion,  ■vvhicli  the  tetanic  I'igidity  and 

spasms  produce  by  obstructing  respiration  and  circulation.  Few  cases 
of  tetanus  infantum  occur  without  more  or  less  extravasation  of  blood, 
either  meningeal  or  cerebral.  Another  cause  of  this  disease  is  obstruc- 
tion in  the  vessels  which  return  the  blood  from  the  brain.  The  various 
structural  changes  Avhich  produce  this  obstruction,  in  different  cases, 
have  been  sufficiently  described  in  our  remarks  on  cerebral  congestion 
and  thrombosis. 

The  congestion  which  precedes  hemorrhage,  when  occurring  under 
the  conditions  described  above,  is  passive. 

Among  the  causes  which  produce  hemorrhage  through  the  inter- 
mediate state  of  active  congestion  may  be  mentioned  great  mental  ex- 
citement, of  which  M.  Legendro  relates  a  case,  and  lengthened  exposure 
to  the  sun's  rays,  an  example  of  which  Rilliet  and  Barthez  have  seen. 
It  is  also  said  that  compression  of  the  aorta  by  an  enlarged  liver  or  an 
abdominal  tumor  has  sometimes  j^roduced  meningeal  or  cerebral  hemor- 
rhage, by  causing  an  increased  afflux  of  blood  to  the  head.  A  very 
important  cause  to  which  I  have  not  alluded,  is  that  general  state  of  the 
circulatory  s^'stem  which  is  designated  ])y  the  term  purjmra  hemor- 
rhagica. This  sometimes  results  from  the  antihygienic  conditions  in 
Avhich  the  child  is  placed.  In  other  instances  it  results  from  some  an- 
tecedent disease,  protracted  and  debilitating,  which  has  produced  a 
profound  alteration  in  the  state  of  the  blood  and  tlie  vessels.  The 
capillaries  become  less  firm  and  elastic,  and  easily  give  way,  so  that  in 
such  patients  ecchymotic  points  are  ordinarily  found  in  different  parts 
of  the  system.  The  diseases  which  occasionally  end  in  this  hemor- 
rhagic diathesis  are  numerous.  I  huve  known  it  to  occur  after  measles, 
scarlet  fever,  and  smallpox.  It  is  also  an  occasional  sequel  of  chronic 
diarrhoea,  or  intermittent  and  typhoid  fevers,  and  of  rachitis. 

Anatomical  Characters. — Ilemon-hage  in  or  upon  the  brain,  in 
infancy  and  childhood,  differs  in  important  particulars  from  that  occur- 
ring in  adult  life.  In  the  adult,  and  more  so  as  life  advances,  the 
arteries  become  less  detensil)le  and  more  brittle,  so  that  when  hemor- 
rhage occurs  it  is  usually  from  one  of  these  vessels.  In  early  life,  on 
tJie  other  hand,  the  blood  does  not  ordinarily  escape  from  an  artery, 
but,  as  has  been  stated,  from  the  capillaries.  The  extravasation  is  not, 
therefore,  so  rapid  and  violent,  and  is  not  attended  by  such  laceration 
and  injury  of  surrounding  parts,  in  infancy  and  childhood,  as  at  a  sub- 
sequent age.  In  the  adult  the  hemorrhage  commonly  occurs  in  the 
substance  of  the  brain.  The  floAV  of  blood  from  the  ruptured  artery 
separates  the  brain-substance,  producing  a  cavity  in  which  a  clot  forms. 
This  constitutes  the  usual  form  of  apoplexy  in  the  adult.  In  the  first 
years  of  life,  on  the  contrary,  the  extravasation  is  commonly  from  the 
meninges,  and  tlie  symptoms  to  which  the  effused  fluid  gives  rise  are  for 
the  most  part  due  to  its  mechanical  effect.  Cases  of  hemorrhage  in  the 
substance  of  the  brain  constitute  a  small  minority,  unless  during  the 


ANATOMICAL    CHARACTERS.  435 

days  immediately  succeeding  birth.  In  early  life,  therefore,  on  account 
of  its  greater  frequency,  meningeal  hemorrhage  is  a  disease  of  more 
importance  than  cerebral,  and  its  anatomical  character  should  be  care- 
fully studied. 

In  meniiKjeal  hemorrhage  the  extravasation  may  be  between  the 
cranium  and  dura  mater,  ui)on  the  visceral  layer  of  the  arachnoid,  in 
the  meshes  of  the  pia  mater,  or  in  a  lateral  ventricle,  from  rupture  of 
the  capillaries  in  the  choroid  plexus.  Much  the  most  common  seat  is 
external  to  the  pia  mater  in  the  so-called  cavity  of  the  arachnoid ;  the 
blood  escaping  in  this  situation  spreads  uniformly  in  all  directions.  It 
soon  separates  in  two  portions,  the  solid  and  liquid.  The  solid  portion, 
or  the  clot,  is  free  or  but  slightly  attaclied  to  the  adjacent  membrane. 
The  meninges  in  the  vicinity  of  the  extravasated  blood  preserve  their 
normal  appearance,  or  are  but  slightly  injected ;  the  clot  gradually 
becomes  extended  on  all  sides,  so  as  to  form  a  lamina  at  the  seat  of  the 
extravasation,  thinner  at  its  circumference  than  centre,  and  at  first  of  a 
dark  red  color.  The  color  gradually  fades,  and  the  lamina,  becoming 
smooth  and  polished,  and  at  the  same  time  more  and  more  attenuated, 
finally  resembles  the  arachnoid  in  appearance.  Its  diameter  varies  in 
different  cases  from  a  few  lines  to  tAvo  or  thi-ee  or  more  inches.  M. 
Tonnele  relates  two  observations  in  wdiich  the  adventitious  membrane 
extended  over  the  superior  surface  of  both  hemispheres,  and  in  one  of 
them,  also,  over  the  falx  cerebri. 

The  extravasation  may  occur  at  any  part  of  the  surface  of  the  Ijrain, 
but  its  usual  seat  is  the  vertex.  The  next  most  frequent  locality  is  the 
base  of  the  brain.  The  subsequent  history  of  the  delicate  membrane 
into  which  the  clot  is  gradually  transformed  is  interesting.  It  often 
extends  so  as  to  cover  more  space  than  was  occupied  by  the  extrava- 
sated blood,  and  its  edges  are  then  scarcely  distinguishable,  in  conse- 
quence of  their  extreme  tenuity,  and  their  close  resemblance  to  the 
arachnoid.  Tiie  attachments  of  this  membrane,  so  far  as  it  forms  any, 
are  usually  to  the  parietal  surface  of  the  arachnoid.  Sometimes  a  por- 
tion of  the  membrane  is  attached,  while  the  rest  lies  free,  bathed  on 
either  side  by  the  liquid  portion  of  the  blood  which  still  remains  from 
the  extravasation.  According  to  M.  Legendre,  in  the  most  favoraljlo 
cases,  the  serum  is  absorbed,  and  the  membrane  which  has  resulted  from 
the  clot,  and  which  I  have  described,  becomes  intimately  adherent  to 
the  internal  surface  of  the  dura  mater.  It  forms  an  integral  part  of  this 
membrane,  and  there  only  remain  a  little  thickening  and  increased 
0[iacity,  indicating  the  seat  of  the  extravasation.  The  health  is  fully 
reestal)lished. 

JJiit  the  result  in  other  cases  is  as  follows  :  The  serum  is  not  absorbed, 
and  the  newly  formed  membrane,  uniting  at  points  with  the  inner  sur- 
face of  the  dura  mater,  or  its  arachnoidal  covering,  incloses  the  fluid  so 
as  to  produce  a  circumscribed  hydrocephalus. 

Soinetinics  there  is  only  one  cyst;  in  other  instances  the  membrane, 
especially  if  large,  unites  in  such  a  way  as  to  give  rise  to  more  cysts 
than  one.  The  size  of  the  cyst  varies,  according  to  the  (juantity  of  fluid, 
which  may  be  only  a  few  drachms  or  several  ounces.  Uilliet  and 
Barthez  report  a  case  in  which  there  was  a  j)int  of  fluid  lying  over  each 


436  INTRACRANIAL    HEMORRHAGE. 

hemisphere,  there  being  two  cysts.  If  the  cranial  bones  are  not  united, 
so  that  they  yield  to  the  pressure,  the  size  of  the  cranium  is  increased, 
and  if  the  extravasation  be  confined  to  one  side,  an  inequality  results, 
and  the  synunetry  of  the  head  is  destroyed.  The  fluid  ■\vhicii  causes 
the  enlargement  of  the  head  in  such  cases  is  in  part  the  serum  of  the 
extravasated  blood,  and  in  part  a  subsequent  secretion. 

Various  writers  relate  cases  of  ventricular  hemorrhage.  "  Yalleix  met 
it  in  an  infant  that  died  at  the  age  of  two  days.  In  the  Edm.  Journ. 
of  Med.  and  Surg.,  October,  1881,  an  interesting  easels  related.  A 
boy  nine  years  old  died  of  hemorrhage  in  both  ventricles,  and  also  at 
the  base  of  the  brain  and  in  the  spinal  canal.  In  the  IS'ursery  and 
Childs  Hospital  of  this  city,  the  post-mortem  examination  was  made  of 
an  infant  who  died  at  the  age  of  one  month.  In  the  posterior  cornu  of 
the  left  lateral  ventricle  were  two  clots,  elongated  and  black,  one  larger 
than  the  other.  In  the  corresponding  cornu,  on  the  opposite  side,  was 
a  smaller  clot.  A  similar  post-mortem  appearance  was  observed  at  the 
autopsy  of  a  young  infant  in  the  infant  service  of  Charity  IIos})ital.  .  A 
dark  crescentic  clot  lay  in  each  posterior  cornu.  The  clot,  if  remaining 
a  long  time,  undergoes  degeneration.  In  the  case  of  an  adult,  in  wliich 
a  year  had  elapsed  after  the  extravasation,  I  found  it  to  contain  crystals 
of  cholesterin  and  carbonate  of  lime. 

Cerebral  Hemorrhage,  or  hemorrhage  in  the  substance  of  the 
brain,  may  occur  at  any  time  in  infancy  and  childhood.  The  blood  is 
sometimes  extravasated  in  points,  here  and  there,  over  the  entire  organ, 
or  a  part  of  the  organ;  in  other  cases  it  is  extravasated  in  one  or  per- 
haps two  cavities,  as  in  the  ordinary  form  of  apoplexy  in  the  adult.  In 
the  first  form  of  cerebral  hemorrhage,  or  that  in  which  the  blood  escapes 
from  numerous  points  through  the  brain,  there  is  evidently  little  lacera- 
tion or  injury  of  the  organ.  The  brain-substance  surrounding  the 
hemorrhagic  points  sometimes  preserves  the  usual  appearance.  It  is 
white  and  firm.  In  other  cases  it  presents  a  reddish  or  yellowish  ap- 
pearance, and  is  softened  to  the  depth  of  a  line  or  two.  If  the  hemor- 
rhage occur  in  a  cavity,  as  in  apoplexy  of  adults,  the  nerve-fibres  are 
evidently  torn  and  separated,  and  there  is  more  or  less  compi'ession  of 
the  surrounding  brain-sid^stance.  Unless  the  disease  be  of  long  stand- 
ing, the  cavity  contains  a  dark  and  soft  clot  bathed  with  serum,  which 
has  a  reddish  or  a  yellowish-red  appearance.  The  brain  in  the  immediate 
vicinity  of  the  cavity  is  sometimes  softened.  Ililliet  and  Barthez  state 
that  they  have  seen  eight  cases  of  cerebral  hemorrhage  of  the  capillary 
form;  ten  cases  in  which  the  hemorrhage  was  in  cavities;  and  in  two 
of  the  eighteen  both  forms  were  present.  In  five  of  those  in  wliich  the 
form  was  capillary  the  disease  was  limited  to  portions  of  the  brain,  while 
in  the  remaining  three  the  hemorrhagic  points  Avere  found  in  nearly 
every  part  of  the  brain. 

Apoplectic  cavities  are  seldom  seen  in  the  cerebellum,  and,  Avhether 
the  hemorrhage  be  capillary  or  in  a  cavity,  there  is,  in  most  cases,  as 
previously  stated,  more  or  less  congestion  of  the  vessels  of  the  brain. 

The  projwrtion  of  cases  of  cerebral  to  other  forms  of  hemorrhage  is 
believed  by  some  to  be  greater  in  the  newborn  than  at  any  other  period 
of  life.     Valleix  relates  four  cases  of  intracranial  hemorrhage  occurring 


SYMPTOMS.  437 

at  this  age,  two  of  -which  were  cerebral,  one  ventricuhir,  and  in  the  other 
the  extravasati<ni  was  in  the  cavity  of  the  arachnoid.  Mignot  has  pub- 
hshed  eight  cases  occurring  in  the  newborn,  in  two  of  which  the  hemoi'- 
rhage  was  in  cavities  in  the  cerebrum  ;  in  three,  in  the  lateral  ventricles; 
and  in  three,  external  to  the  brain.  If  the  same  proportion  be  observed 
in  other  statistics,  one  in  three  of  the  cases  of  intracranial  hemorrhage 
occurring  in  the  newborn  is  cerebral. 

Symptoms. — The  symptoms  in  intracranial  hemorrhage  are  not  uni- 
form ;  they  vary  according  to  the  seat  as  well  as  the  quantity  of  the 
effused  blood.  In  some  cases  the  extravasation  occurs  without  such 
symptoms  as  would  direct  attention  to  the  brain.  When  the  hemor- 
rhage occurs  at  the  time  of  birth,  in  consequence  of  strong  and  long- 
continued  labor-pains,  the  infant  is  often  born  apparently  dead.  This 
is  due  partly  to  the  hemorrhage,  partly  to  the  great  congestion  of  the 
brain  which  precedes  and  accompanies  the  hemorrhage.  Resuscitation 
is  gradual  and  difficult.  The  infant's  features  are  livid,  and  perhaps 
swollen;  its  respiration  is  gasping,  and  both  pulse  ami  respiration  are 
slow.  Its  cry  is  feeble,  with  but  slight  movement  of  the  facial  muscles, 
and  the  lungs  are  but  partially  inflated;  the  eyelids  are  closed,  and  the 
limbs  almost  motionless.  By  artificial  respiration  and  by  friction,  the 
pulse  and  breathing  may  be  rendered  more  frequent,  but  the  latter 
remains  irregular  and  gasping.  Finally,  the  liml)S  grow  cold,  the  surface, 
"rem  a  state  of  lividity,  becomes  pallid,  and  death  occurs  in  profound 
coma.  M,  Cruvellliier  made  many  observations  at  the  '"Maternity  "  in 
reference  to  the  death  of  newborn  infjints,  and  he  believes  that  one- 
third  of  those  who  die  in  birth,  at  the  full  period,  die  of  apoplexy,  I 
have  made  post-mortem  examinations  in  a  few  cases,  when  death  had 
occurred  from  this  cause,  and  in  all  the  hemorrhage  was  meningeal. 
One  of  these  was  born  on  the  30th  of  December,  1804.  The  birth  was 
delayed  by  unusual  ])rojection  of  the  promontory  of  the  sacrum,  so  that 
finally  the  application  of  forceps  was  necessary.  The  infant  Avas  appar- 
ently stillborn,  but  by  persistent  efforts  on  the  part  of  the  physician 
who  assisted  it  was  resuscitated  so  as  to  live  several  hours,  though  with 
constant  embarrassment  of  respiration  and  with  lividity.  At  the  autopsy 
a  large  extravasation  of  blood  was  found  in  the  cavity  of  the  arachnoid, 
over  a  considerable  part  of  the  convexity  of  the  brain,  and  the  substance 
of  the  brain  was  deeply  congested. 

Apoplexy  in  the  newborn  does  not  always  terminate  fatally,  or,  when 
fatal,  in  the  sudden  mniiner  Avhich  1  have  descril)ed,  Valleix  relates 
the  case  of  an  infimt  who  died  of  pneumonia  at  the  age  of  three  and  a 
half  months.  Its  birth  had  l)een  protracted  and  difficult,  but  was  com- 
pleted without  the  use  of  instruments.  It  had  had  during  its  entire 
life  paralysis  of  the  right  side.  At  the  autopsy  a  clot  was  found  near 
the  base  of  the  right  thalamus  opticus,  evidently  existing  from  birth. 
Around  the  clot  the  brain  was  softened  to  the  depth  of  some  lines,  and 
was  of  a  bluish-red  color.  A  very  similar  case  is  relate<l  by  M.  Xar- 
nois.  An  infant  lived  forty-nine  days  with  ])aralysis  of  the  left  side, 
and  died  of  [)neumonia.  At  the  autopsy  a  hemorrhagic  excavation  in 
l)roces3  of  cicatrization  was  found  behiiKl  the  right  corpus  striatum  and 
the  thalamus  opticus. 


438  INTRA  CRANIA].    HEMORRHAGE. 

Intracranial  hemorrhage  occurring  from  accidents  of  birth  is  gener- 
ally attended  by  marked  symptoms,  such  as  have  been  described. 
But  when  it  occurs  subsequently  to  birth,  whether  in  infancy  or  child- 
hood, the  symjjtoms  vary  greatly  in  different  cases,  and  are  generally 
obscure.  I  will  briefly  state  the  symptoms  which  have  been  observed 
in  both  the  cerebral  and  meningeal  forms  of  this  disease.  First,  the 
cerebral.  Sedillot  relates  the  case  of  a  child  seven  and  a  half  years 
old,  whose  bare  head  had  been  exposed  several  hours  to  the  sun's  rays. 
Suddenly,  after  a  pai'oxysm  of  anger,  it  was  seized  with  great  pain, 
corresponding  with  the  posterior  and  inferior  foss;B  of  tlie  cranium.  It 
uttered  piercing  cries,  and  died  in  a  quarter  of  an  hour.  A  clot  was 
found  in  the  right  lobe  of  the  cerebellum.  Richard  Quinn  (Rilliet  and 
Barthez)  gives  the  history  of  a  boy  nine  years  old,  who  in  playing  with 
a  hoop  suddenly  stopped,  carried  his  hands  to  his  head,  and  fell  back- 
ward unconscious.  Three  or  four  hours  afterward  when  examined,  he 
was  found  pale,  surfixce  cool,  respiration  slow  and  at  times  stertorous, 
pulse  50  to  60  per  minute ;  the  left  arm  was  flexed,  the  left  leg  para- 
lyzed ;  the  right  leg  and  arm  convulsed ;  right  pupil  strongly  dilated, 
the  left  contracted.  He  died  seven  hours  after  the  commencement  of 
the  attack,  and  a  large  clot  was  found  in  the  centrum  ovale  on  the  right 
side. 

Rilliet  and  Barthez  relate  the  following  case  from  Campbell.  A 
boy  Avith  good  previous  health  was  suddenly  seized  about  7  A.  m.  with 
repeated  vomiting,  and  in  an  hour  and  a  half  with  violent  convulsions ; 
he  rolled  his  eyes  and  uttered  inarticulate  cries ;  pulse  frequent  and 
hard  ;  pupils  contracted ;  trunk  and  lower  extremities  cool.  In  the 
afternoon  he  presented  symptoms  of  compression  of  the  brain,  such  as 
dilatation  of  the  pu])ils,  frequent  and  feeble  pulse.  Death  occurred  in 
the  evening,  and  a  hemorrhagic  cavity  was  found  occupying  the  right 
middle  lobe  of  the  cerebrum.  Guibert  relates  a  c:ise  of  extravasation  in 
the  superior  part  of  the  right  hemisphere  of  the  brain  in  a  boy  fourteen 
years  old.  The  principal  symptoms  were  feebleness  of  the  limbs,  ina- 
bility to  walk,  cephalalgia,  involuntary  evacuations,  fever,  grinding  of 
the  teeth,  rigors  severe  and  prolonged,  lividity,  loss  of  intellectual  facul- 
ties, dilatation  of  the  pupils,  insensibility  to  light,  stertorous  respiration. 
Death  occurred  in  about  an  hour. 

Rilliet  and  Barthez  narrate  the  history  of  a  girl  two  years  old,  who, 
after  an  attack  of  measles,  was  taken  with  convulsions  accompanied 
with  fever  and  prostration.  The  convulsive  movements  affected  especi- 
ally the  eyes  and  uj)pcr  extremities  ;  the  riglit  leg  was  immovable  ;  the 
left  pupil  dilated.  These  symptoms  resulted  fi'oin  hemorrhage  in  the 
corpus  striatum  and  opticus  thalamus.  The  san)e  authors  relate  also 
the  case  of  a  girl,  seven  years  old,  who  died  with  a  large  apoplectic 
cavity  in  the  left  thalamus  opticus.  The  symptoms  were  headache, 
convulsive  movements,  loss  of  consciousness,  delirium,  vomiting  and 
constipation,  and  convergent  strabismus.  These  symptoms  nearly  dis- 
appeared, but  in  a  few  days  the  headache  returned,  with  strabismus  and 
a  slight  drawing  of  the  face  toward  the  left;  on  the  twenty-seventh  day 
convulsive  movements  of  the  right  eye  were  observed,  with  paralysis  of 
the  arm.     Finally  contraction  of  the  arms  occurred,  with  acceleration 


SYMPTOMS,  439 

of  pulse,  irregular  breathing,  dilated   pupils,  paralysis,   and   retraction 
of  the  head,  followed  by  death  on  the  forty-eighth  day. 

These  cases,  and  those  from  Valleix  and  Vernois,  which  have  been 
related  in  our  remarks  on  hemorrhage  of  the  newborn,  are  sufficient  to 
show  the  character  of  the  symptoms  in  that  form  of  cerebral  hemor- 
rhage in  which  tlie  extravasated  blood  forms  a  cavity  in  the  interior  of 
the  brain. 

If  the  amount  of  extravasation  be  large,  and  the  substance  of  the 
brain  be  much  lacerated  and  compressed,  death  may  occur  almost  imme- 
diately, and,  therefore,  without  symptoms,  or  before  it  is  possible  to 
determine  Avhether  or  not  symptoms  are  present.  If  the  disease  be  not 
so  speedily  fatal,  the  symptoms,  as  appears  from  the  above  cases,  are 
headache,  confusion  of  thought,  or  even  insensibility,  cries,  sometimes 
piercing,  cold  extremities,  pallor,  slow  and  perhaps  stertorous  respira- 
tion, convulsive  movements  followed  by  paralysis,  or  convulsions  affect- 
ing one  or  more  limbs,  Avith  paralysis  of  others,  pupils  contracted  or 
dilated,  sometimes  one  contracted  and  the  other  dilated,  strabismus, 
rollinfj  of  eves,  vomitim;. 

These  symptoms  have  all  been  observed  in  different  cases,  but  they 
are  not  all  present  in  any  one  case.  Those  which  are  generally  present, 
and  on  which  we  mainly  rely  for  diagnosis,  are  headache,  convulsive 
movements,  paralysis,  confusion  of  thought,  irregularity  in  the  pupils, 
and  strabismus. 

In  the  CAPILLARY  form  of  cerebral  hemorrhage  there  is  usually  some 
comj)lication,  so  that  it  is  not  easy  to  determine  how  far  symptoms  are 
due  to  the  hemorrhage,  and  how  far  to  the  coexisting  pathological  state. 

There  are,  indeed,  but  few  published  observations  of  cerebral  hemor- 
rhage in  the  substance  of  the  brain  unaccompanied  with  meningeal  hemor- 
rhage, hemorrhage  into  a  ventricle,  or  some  other  distinct  disease,  but 
so  far  as  I  have  been  a])le  to  ascertain  the  symptoms  referable  to  this 
form  of  extravasation,  they  are  as  follows:  The  child  is  drowsy;  fretful 
when  disturbed;  it  perhaps  moans.  There  are  sometimes  slight  con- 
vulsive movements  and  partial  paralysis.  If  there  be  considerable  ex- 
travasation, the  respiration  is  irregular  and  sighing.  Death  occurs  in 
coma,  occasionally  preceded  by  convulsions.  Tau]»in  relates  the  case  of 
a  child  nine  years  old,  who  died  with  this  form  of  hemon-hage,  accom- 
panieil  )>y  softening  of  the  brain.  The  disease  began  at  night,  with 
delirium,  agitation,  and  piercing  cries.  In  the  morning  the  patient  lay 
in  bed,  drowsy,  not  complaining  of  pain,  and  not  replying  to  ((uestions; 
pupils  dihited,  and  insensil)le  to  light;  left  eye  half  ojien  during  sleep, 
and  its  axis  ciiangcd;  eyebrows  C(tntracted;  fice  pale;  mouth  0])cn; 
had  no  convulsions,  but  transient  stitt'ening  of  the  limbs,  during  which 
the  thumbs  were  firmly  compressed  by  the  fingers;  senses  unimpaired, 
but  the  face  drawn  to  the  right;  deglutition  difficult;  ])ulse  small,  ir- 
regular, and  feeble;  res])iration  32,  sighing.  In  the  evening  he  had 
rigidity  of  the  limbs  and  back,  and,  finally,  was  taken  with  general  con- 
vulsions, in  which  he  dieil  at  eleven  o'crlock.  The  hcmori-hagic  ])oints 
in  this  case  were  numerous.  A  boy  five  years  old,  whose  case  is  de- 
scribed by  Rilliet  and  Barthez,  dicMl  of  this  disease,  pneumonia,  and 
white  softening  of  the  intestine.     During  the  last  five  days  there  were 


4.4:0  INTRACRANIAL  HEMORRHAGE. 

cerebral  symptoms,  the  chief  of  ^vhich  Avere  drowsiness,  fretfulness  wlien 
disturbed,  and  moaning  without  apparent  cause.  Another  chihl,  whose 
case  is  described  by  Rilliet  and  Barthez,  died  at  the  age  of  four  years, 
with  cerebral  capillary  hemorrhage,  accompanied  by  yellow  softening. 
Six  months  before  death  he  had  general  convulsions,  followed  by  spas- 
modic movements  of  the  left  side.  These  subsided,  but  the  left  side 
remained  feeble. 

In  Meningeal  Hemorrhage  there  are  often  convulsions,  general  or 
partial,  in  some  patients  tonic,  in  others  clonic.  When  partial,  the 
convulsive  movements  may  only  occur  in  the  muscles  of  the  face  and 
eyes.  With  the  spasmodic  muscular  action  is  a  degi'ee  of  drowsiness 
and  irritability.  Paralysis,  so  common  in  the  apoplexy  of  the  adult,  and 
not  infreijuent,  as  we  have  seen,  in  the  cerebral  form  of  early  life,  is 
sometimes,  but  not  ordinarily,  present  in  meningeal  hemorrhage.  In- 
stead of  paralysis,  there  are  vomiting,  some  febrile  action,  thirst,  and 
loss  of  appetite.  The  symptoms  are  different,  however,  according  to 
the  exact  seat  of  the  hemorrhagic  extravasation,  and  the  duration  of  the 
disease.  If  the  extravasation  end  in  the  formation  of  a  cyst,  the  symp- 
toms are  those  of  hydrocephalus.  The  following  condensed  history  of 
cases  which  I  have  selected  as  typical,  will  give  us  a  clearer  idea  of  the 
history  and  course  of  the  various  forms  of  meningeal  hemorrhage  than 
can  be  imparted  by  a  narration  of  symptoms: 

M.  Tonnele  relates  the  case  of  a  child  who  was  taken  with  faintness 
and  convidsive  movements.  On  the  following  day  the  trunk  and  inferior 
extremities  became  rigid;  deglutition  was  painful;  the  pupils  were 
largely  dilated,  immovable;  face  pale;  pulse  feeble  and  intermittent. 
Death  occurred  the  same  day.  The  dura  mater  was  distended.  A 
layer  of  coagulated  blood,  of  great  thickness,  extended  over  the  con- 
vexity of  each  hemisphere.  The  veins  ramifying  in  the  superior  portion 
of  the  cerebrum  were  distended  with  coagulated  blood.  Tlie  hemorrhage 
■was  in  the  meshes  of  the  pia  mater.  Drs.  Loml)ard  and  Panchard,  of 
Geneva,  relate  a  somewhat  similar  case.  A  child,  thirteen  months  old, 
was  convalescing  from  inflammation  of  the  bronchial  and  intestinal 
mucous  surfaces,  when  it  was  seized  with  general  convulsions;  the  mouth 
and  eyes  were  open,  and  the  eyes  directed  u])ward;  pupils  contracted; 
pulse  frequent  and  irregular.  The  convulsions  abated  somewhat;  but 
soon  reap])eared  with  violence.  The  ])atient  became  insensible,  and 
died  nineteen  hours  after  the  commencement  of  cerebral  symptoms. 
The  extravasated  blood  covered  the  upper  surface  of  both  hemispheres. 
From  the  above  cases  we  see  the  symptoms  and  the  course  of  meningeal 
hemorrhage,  when  the  extravasation  is  so  large  that  death  speedily 
results.  In  protracted  cases  of  meningeal  hemorrhage,  there  is  either  a 
gradual  disappearance  of  symijtoms  and  return  to  health,  or,  circum- 
scribed hydrocephalus  occurring,  the  symptoms  of  that  disease  arise. 

Diagnosis. — It  is  evident,  from  what  has  been  stated,  that  the  diag- 
nosis of  intracranial  hemorrhage  is  attended  with  unusual  difficulty,  since 
the  symptoms  of  tliis  disease  occur  also  in  other  and  distinct  pathological 
states.  The  history  of  the  case,  and  especially  the  character  of  the 
cause,  if  ascertained,  will  aid  in  diagnosis.  If  there  have  been  an  obvi- 
ous determination  of  blood  to  the  brain,  or  some  known  obstruction  to 


TREATMEXT.  441 

the  return  of  blood  from  that  organ,  t]ie  persistence  of  cerebral  symp- 
toms would  justify  us  in  concluding  that  either  serous  or  sanguineous 
effusion  had  supervened  on  a  state  of  congestion.  The  points  of  differ- 
ential diagnosis  between  apoplexy  and  meningitis  are  the  sudden  and 
full  development  of  symptoms  in  one  case,  the  gradual  commencement 
and  gradual  increase  of  symptoms  in  the  other;  differences  also  of  symp- 
toms in  certain  respects;  for  example,  as  regards  febrile  reaction,  con- 
stipation, etc. 

There  is  one  symptom  in  cerebral  hemorrhage  which  is  of  great  diag- 
nostic value,  namely,  paralysis.  Its  presence  affords  strong  evidence 
that  there  is  extravasation  of  blood,  and  probably  in  a  cavity  in  the  sub- 
stance of  the  brain.  If  the  extravasation  end  in  the  formation  of  a  cyst, 
the  svmjttoms  and  appearance  of  hydrocephalus,  which,  after  a  time, 
arise,  throw  light  on  the  nature  of  the  disease. 

PiiOGXOSis. — There  caa  be  no  doubt  that  many  cases  of  intracranial 
hemorrhage  occur  and  terminate  favorably  without  the  nature  of  the 
disease  being  suspected.  In  such  cases  the  amount  of  extravasated 
blood  is  small  or  moderate.  In  several  published  cases  in  which  the 
accuracy  of  the  diagnosis  was  shown  by  post-mortem  examinations,  the 
patients  were  convalescing  from  the  hemorrhage  when  they  succumbed 
to  intercurrent  diseases.  If,  however,  the  amount  of  extravasated  blood 
be  such  as  to  give  rise  to  those  symptoms  Avhich  have  been  described, 
the  prognosis  is  unfavorable.  Recurring  convulsions,  and  persistent 
stupor  from  which  it  is  difficult  to  arouse  the  patient,  are  unfavorable 
symptoms.  If  the  convulsions  cease,  and  consciousness  return,  even  if 
there  be  paralysis,  the  result  may  be  favorable. 

Treatment. — The  proper  treatment  in  intracranial  hemorrhage  de- 
pends on  the  state  of  the  patient,  the  time  which  has  elapsed  since  the 
extravasation,  and  the  degree  of  it.  tus  shown  by  the  nature  and  severity 
of  the  symptoms.  If,  as  is  often  the  case,  the  patient  be  robust,  and  be 
visite<l  soon  after  the  commencement  of  the  attack,  cold  applications 
should  be  made  to  the  head,  niustard  to  the  back  of  the  neck  and  per- 
haps chest,  and  derivation  should  be  produced  by  mustard  pediluvia. 
In  many  cases,  especially  in  active  congestion,  it  is  advisable  to  apjjly 
leeches  to  the  temple,  and  the  bowels  should  be  opened  by  a  stimulating 
eneuia.  In  active  congestion,  also,  prompt  purgation  by  salines  or  othei* 
cathartics  is  sometimes  of  great  importance.  The  object  of  such  treat- 
ment is  to  relieve  congestion  of  the  cerebral  and  meningeal  vessels,  and 
thereby  prevent  further  extravasation  of  blood.  If  the  congestion  be 
active,  the  i)ulse  continue  full  and  fre(juent,  and  the  face  be  ffushed,  it 
is  |)ropor  in  many  cases  to  control  the  action  of  the  heart  by  a  seda- 
tive. For  this  purpose  the  tincture  of  aconite  root  may  be  given  in 
doses  of  one  drop  to  a  child  five  years  oM,  repeated  in  three  hours  if 
necessary,  or  veratrum  viride  may  be  used.  If  the  stupor  or  convul- 
sions continue  after  sufficient  time  have  elapsed  for  the  patient  to  receive 
the  fidl  benefit  of  the  above  rcnuidies,  more  active  counter-irritation  is 
re(piired.  Cantharidal  collodion  should  be  applied  b(.'hind  each  car.  If 
tlie  liL-morrhage  occur  from  ])assive  congestion,  or  in  a  cathectic  state  of 
system,  active  depressing  reme<lies  shouM  not  be  employed.  External 
derivatives  are  of  service,  as  well  as  cool  applications  to  the  head,  an<l 


442  CONGENITAL    HYDROCEPHALUS. 

we  should  attempt,  so  far  as  possible,  to  remove  the  cause  of  the  con- 
gestion and  hemorrhage.  If  it  depend  on  a  cachectic  state,  tonic  or 
other  remedies  calculated  to  relieve  this  state  are  indicated.  The  hemor- 
rhage from  such  a  cause  is  usually  in  points  in  the  substance  of  the 
brain,  or  in  moderate  quantity  over  the  surface  of  this  organ,  and  by  a 
timely  use  of  constitutional  remedies  possibly  we  may  prevent  further 
extravasation  of  blood  and  increase  the  chance  of  the  })atient"s  recovery. 
If  a  cyst  result  from  ttie  hemorrhagic  effusion,  the  treatment  which  is 
proper  is  that  described  in  the  chapter  on  Acquired  Hydrocephalus. 


CHAPTER  YII. 

CONGENITAL  HYDROCEPHALUS. 

Congenital  hydrocephalus  consists  in  an  excess  of  the  cerebro-spinal 
fluid,  lying  either  external  to  the  brain,  or  more  frequently  in  its  in- 
terior. It  is  due  to  some  vice  in  the  development  of  the  brain  or  its 
membranes,  or  to  a  pathological  state  occurring  in  them  during  intra- 
uterine life.  This  disease  is  ordinarily  apparent  from  the  symptoms  and 
appearances  at  birth,  but  not  always.  Occasionally  nothing  unusual  is 
observed  in  the  shape  of  the  head  or  aspect  of  the  infant  till  after  the 
lapse  of  some  weeks,  wdien  the  characteristic  physiognomy  begins  to 
appear.  In  these  cases  the  disease  is  still  congenital,  since  there  is 
every  reason  to  believe  that  the  abnormal  state  to  which  the  excessive 
pi-oduction  of  fluid  is  due  existed  from  birth.  In  cases  of  arrested  or 
partial  development  of  the  brain,  as,  for  example,  when  a  considerable 
portion  of  the  hemispheres  is  absent,  there  is  often  an  unusually  large 
quantity  of  fluid  which  serves  as  a  compensation  for  the  lack  of  brain. 
I  do  not  regard  such  cases  as  examples  of  hydrocephalic  disease,  since 
the  effect  of  the  fluid  is  not  injurious,  but  rather  useful.  I  restrict  the 
term  congenital  hydrocephalus  to  those  cases  in  Avhich  the  brain  is  com- 
plete, or,  if  incomplete,  the  quantity  of  fluid  is  more  than  sufficient  to 
supply  the  deficiency. 

Anatomical  Characters. — According  to  M.  Breschet,  the  fluid  in 
congenital  hydrocephalus  may  be — 1st,  between  the  dura  mater  and  the 
cranium  ;  2d,  between  tlic  dura  mater  and  the  parietal  arachnoid  ;  3d, 
in  the  cavity  of  the  arachnoid ;  4th,  in  the  ventricles;  5th,  between  the 
arachnoid  and  the  brain. 

In  a  large  majority  of  hydrocephalic  patients  the  effusion  occurs  in 
the  ventricles.  As  the  quantity  of  fluid  increases,  the  pressure  from 
within  gradually  unfolds  the  convolutions  of  the  brain,  at  the  same  time 
producing  expansion  of  the  cranial  arch.  When  the  amount  of  fluid  is 
considerable,  and  it  becomes  so  in  the  course  of  a.  few  weeks  or  months. 


ANATOMICAL    CHARACTERS, 


443 


the  hemispheres  are  spread  out  in  a  thin  lamina  on  either  side,  gradually 
decreasing  in  thickness  from  the  base  of  the  cranium  to  the  vertex, 
where  the  brain-substance  is  sometimes  so  thin  as  to  be  scarcely  per- 
ceptible. Complete  absence  of  brain  in  this  situation,  namely,  at  the 
vertex,  even  in  extreme  cases  of  expansion  and  flattening  of  the  hemi- 
spheres from  the  pressure  of  the  lir|uid,  is  rare,  though  the  brain-sub- 
stance at  this  point  is  sometimes  almost  as  thin  as  either  of  the  mem- 
branes, so  that  the  wall  of  the  sac  is  translucent.  The  membranes  which 
surround  the  brain  do  not  usually  undergo  any  alteration,  except  such 
as  arises  from  the  distention.  The  falx  cerebri  sometimes  disappears, 
and  sometimes  the  meninges  present  a  whiter  hue  from  maceration  than 
in  health.  The  distention  also  causes  such  an  expansion  of  the  pia 
mater  that  it  becomes  very  thin,  and  in  places  scarcely  visible,  but  its 
presence  in  every  point  can  be  demonstrated. 

The  accompanying  woodcut  represents  congenital  hydrocephalus  as  it 
ordinarily  occurs.  I  saw  this  infant  when  it  was  a  few  days  old,  and 
examined  it  from  time  to  time  till  its  death.  The  parents  are  healthy 
and  have  other  healthy  children.     This  infant  Avhen  nine  days  old  began 

Fig.  28. 


to  have  clonic  convulsions  of  a  milil  form  in  the  muscles  of  the  face, 
neck,  and  limbs,  which  occurred  almost  daily  till  the  age  of  six  weeks, 
and  sometimes  every  five  or  ten  minutes.  When  the  convulsi(ms 
ceased  in  the  sixth  week,  the  head  was  observed  to  enlarge,  and  its 
excessive  growth  continued  till  death,  which  occurred  at  tlic  ago  of 
seven  months  and  one  week.  While  the  volume  of  the  liead  progres- 
sively increased,  the  trunk  and  liml)9  emaciated.  At  death  the 
occipito-frontal  circumference  of  the  head  was  nineteen  and  a  half 
iiu'hes;  the  vertical  from  auditoi'v  meatus  to  meatus  tliirtecu  and  a 
lialf  inches. 

The  changes  Avhich  the  cranial  bones  undergo,  both  in  their  chemical 


444  CONGENITAL  HYDROCEPHALUS. 

character  ami  in  their  shape,  in  hydrocephalic  patients,  if  the  amount 
of  fluid  be  considerable,  are  interestini^  and  remarkable.  The  base  of 
the  cranium  undergoes  little  change,  but  those  portions  of  the  frontal, 
parietal,  and  occipital  bones  which  constitute  the  arch  are  exjjanded  in 
all  directions,  while  they  become  much  thinner.  There  is  deficiency  of 
lime  in  their  constitution,  so  that  the  organic  elements  are  greatly  in 
excess.  This  renders  them  flexible  and  semi-transparent.  Notwith- 
standing the  expansion  of  the  bones,  there  are  usually  interspaces 
between  them,  of  greater  or  less  size,  according  to  the  amount  of  fluid. 

The  scalp,  being  stretched  by  the  pressure  underneath,  becomes 
tense  and  thin,  and  is  scantily  covered  with  hair.  The  veins  which 
ramify  in  it  are  unusually  prominent  and  large,  and  the  head  is  elastic 
on  pressure,  from  the  amount  of  liquid  beneath.  In  the  common  form 
of  congenital  hydrocephalus,  namely,  that  in  which  the  licjuid  is  in  the 
interior  of  the  brain,  the  shape  of  the  orbital  plates  of  the  frontal  bone 
is  often  changed,  so  that  the  eyeballs  have  a  downward  direction.  This 
change  in  the  axis  of  the  eyes  occurs  at  an  early  period,  and  it  continues 
through  the  entire  disease,  becoming  more  and  more  marked  as  the 
(pumtity  of  licpiid  increases.  If  the  amount  be  large,  the  lower  part  of 
the  cornea  is  buried  under  the  under  eyelid,  while  tlie  conjunctiva  is 
visible  between  the  cornea  and  the  upper  eyelid.  The  persistent  down- 
Avard  direction  of  the  eyes  is  characteristic  of  this  disease,  and,  in  con- 
nection with  enlargement  of  the  head,  is  an  important  diagnostic  sign. 
Nevertheless,  hydrocephalus  even  of  the  ventricular  variety,  sometimes 
occurs  without  change  in  the  direction  of  the  eyes. 

If  Ave  examine  the  interior  of  the  cavity  after  the  fluid  is  evacuated, 
Ave  Avill  find  at  its  base  the  parts  which  lie  in  the  floor  of  the  lateral 
ventricles,  but  changed  in  appearance  in  consequence  of  pressure.  The 
cornua  are  enlarged,  and  the  thalami  optici  and  corpora  striata  are  flat- 
tened. In  the  early  stages  of  the  disease,  when  the  amount  of  fluid  is 
small,  there  is  probably  no  absorption  or  destruction  of  parts  in  the 
interior  of  the  brain.  The  various  portions  of  this  organ  retain  nearly 
their  normal  relation  to  each  other.  As  the  quantity  of  fluid  increases, 
the  foramen  of  Monro,  which  unites  the  lateral  ventricles,  becomes 
enlarged,  the  septum  lucidum  which  separates  them  disappears,  and  the 
tAvo  ventricles  form  a  common  cavity.  In  most  fatal  cases  we  find  this 
single  large  cavity.  The  surface  Avhich  surrounds  tlie  cavity  occasion- 
ally presents  a  Avhitish  or  semi-opaque  appearance,  Avhich  has  led  to  the 
belief,  that  at  a  period  antecedent  to  birth  there  was  subacute  inflam- 
mation of  this  surface,  and  hence  the  effusion. 

The  bones  of  the  face  are  ordinarily  less  developed  than  in  healthy 
children  of  the  same  age,  so  that  the  disproportion  betAveen  the  head 
and  face  becomes  a  marked  peculiarity.  The  shape  of  the  forehead 
and  face  is  nearly  triangular. 

The  f  )regoing  remarks  in  reference  to  the  anatomical  cliaracters  of 
congenital  hydrocephalus  refer  in  tlie  main  to  cases  A\'hicli  have  c(m- 
tinued  for  a  considerable  time,  so  that  their  characteristic  features  are 
Avcll  marked.  In  very  young  infants,  in  whom  the  disease  is  still  recent, 
similar  anatomical  characters  are  present,  but  in  less  degree. 

Congenital  hydrocephalus  is  often  associated  Avith  other  vices  of  con- 


ETIOLOGY, 


445 


Tui.  20. 


formation,  especially  with  spina  bifida.  The  two,  when  coexisting,  are 
only  parts  of  the  same  disease;  the  large  quantity  of  cerebro-spinal 
fluid  preventing  the  spinal  canal  from  closing  during  foetal  develop- 
ment. 

The  fluid  in  congenital  hydrocephalus  consists  largely  of  water,  in  the 
proportion  even  of  Jr'O  parts  in  lUO.  In  addition  to  this  element,  there 
are  traces  of  albumen,  chloride  of  sodium,  phosphate  and  carbonate  of 
sodium,  and  osmazome. 

I  have  had  an  opportunity  to  witness  only  one  post-mortem  examina- 
tion in  a  case  of  congenital  hydrocephalus  in  which  the  li(iuid  was  ex- 
terior to  the  brain.  This  case  Avas  under  observation  in  the  cldldrens 
service  of  Charity  Hospital,  in  1S()C.  Full  notes  and  measurements  of 
the  head  were  taken,  which,  unfortunately,  were  mislaid  or  lost.  The 
infant  had  congenital  syphilis,  and  had  a 
pallid,  strumous  appearance.  The  shape  and 
relative  size  of  the  head  are  seen  in  the  ac- 
companying figure,  from  a  photograph.  While 
the  whole  head  Avas  enlarged,  there  was  a 
relative  excess  of  development  in  the  part 
between  and  above  the  ears.  The  axis  of  the 
eyes  was  not  at  all  changed,  and  the  vision 
was  good.  The  appearance  corresponded  so 
closely  with  descriptions  of  hypertro])hy  of 
the  brain  that  this  was  su])posed  to  be  the 
anatomical  state.  Antisyphilitic  treatment 
was  employed,  and  the  syphilitic  eruptions  had 
nearly  disappeared,  when  diarrhoea  super- 
vened, followed  by  death.     At  the  autopsy  a 

quantity  of  transparent  or  light  straw-colored  liquid,  estimated  at  six  or 
seven  ounces,  was  found  exterior  to  the  brain,  in  the  great  cavity  of  the 
arachnoid,  lying  mostly  over  the  superior  surfiice  of  the  organ.  There 
was  no  excess  of  liquid  in  the  ventricles,  and  the  brain,  though  of  good 
size,  was  not  abnormally  large,  nor  did  it  possess  the  firmness  which  is 
present  in  true  hypertrophy. 

All  cases  of  congenital  liydrocephalus  may  be  embraced  in  two  groups, 
namely,  that  in  which  the  litpiid  is  in  the  interior  of  the  brain,  and  that 
in  which  it  lies  exterior  to  the  organ.  Li(i[uid  primarily  in  the  arach- 
noidean  cavity  permeates  the  meshes  of  tlie  pia  mater,  and  lies  in  part 
underneath  it,  or  this  delicate  membrane  may  be  ruptured.  Four  of 
the  groups,  therefore,  described  by  IJreschet,  may  properly  be  reduced 
to  one,  namely,  tintse  grou[)S  in  which  the  li(piid  lies  under,  between,  or 
external  to  tlie  meninges.  It  is  probable  that  some  of  the  cases  wiiicli 
le<l  to  JJrescliet's  classification  were  examples  of  acquired  circumscribed 
liydrocephalus,  the  result  of  extravasation  of  blood.  In  this  form  of 
hydrocephalus,  as  is  stated  elsewhere,  an  adventitious  membrane  forms 
external  to  the  liquid,  becoming  in  time  thin  and  delicate,  and  often 
bearing  a  close  resemblance  to  the  normal  membrane  (especially  the 
arachnoid),  fi»r  wliicli  it  is  sometimes  inistaken. 

Ftioloov. — The  constitutional  vice  which  gives  rise  to  this  disease 
is  probably  different  in  different  cases.     I  have  been  able,  I  think,  to 


446  CONGENITAL    HYDROCEPHALUS. 

attribute  correctly  a  considerable  proportion  of  cases  Avhicli  I  liave  ob- 
served, to  congenital  syphilis,  but  in  other  instances,  from  the  character 
of  the  parents  I  could  not  assign  this  cause. 

Symptoms. — If  there  be  a  considerable  amount  of  hydrocephalic  fluid 
prior  to  the  birth  of  the  child,  so  that  the  head  is  abnormally  large,  par- 
turition is  seriously  interfered  Avith.  The  scalp  and  meninges  may 
become  ruptured  by  the  severity  of  the  pains,  so  that  the  fluid  escapes. 
If  this  do  not  occur,  the  labor  is  often  necessarily  instrumental. 
Whether  the  liquid  be  present  before  birth  or  accumulate  subsequently 
to  it,  the  tendency  is  to  an  increase  of  the  quantity,  and  a  correspond- 
ing enlargement  of  the  head. 

The  digestive  function  in  this  disease  is  at  first  well  performed.  The 
infint  nurses  readily,  and  has  its  evacuations  with  the  regularity  of 
other  children.  Not  many  weeks,  however,  elapse,  in  the  majority  of 
cases,  before  defective  nutrition  is  apparent. 

While  the  volume  of  tha  head  increases,  other  parts  are  imperfectly 
nourished  and  stunted  in  their  growth.  Emaciation  of  the  neck,  trunk, 
and  limbs  is  common,  associated  with  progressive  feebleness.  In  the 
last  stages  of  this  disease  there  is  more  or  less  vomiting,  with  constipa- 
tion. If  there  were  previously  the  aljility  to  support  the  head,  it  is  now 
lost  and  the  erect  position  is  no  longer  possible.  In  marked  cases, 
when  there  is  great  disproportion  between  the  head  and  the  rest  of  the 
system,  there  is  frequently  not  even  the  ability  to  rotate  the  head  on  the 
pillow.  So  long  as  the  cranial  bones  yield  readily  to  the  pressure  from 
within,  and  there  is  no  compression  of  the  brain,  the  function  of  this 
organ  is  not  seriously  impaired.  The  child  recognizes  its  mother  or 
nurse,  and  it  can  be  amused  like  other  children,  though  easily  fatigued. 
The  state  of  the  senses  is  different  in  different  cases,  and  sometimes  at 
different  stages  of  the  same  case.  The  sight  and  hearing  in  some  are 
perfect,  in  otliers  impaired;  while  in  others  still  they  are  good  at  first, 
but  gradually  become  obscured  and  lost.  It  is  said  that  the  sense  of 
smell  may  be  perverted,  so  that  agreeable  odors  are  unpleasant,  and 
vice  versa.  Many,  reaching  the  age  at  which  children  begin  to  walk, 
cannot  walk,  or,  if  they  do,  it  is  with  a  tottering,  unsteady  gait. 

When  the  liquid  increases  to  that  extent,  and  it  usually  does  sooner 
or  later,  that  the  brain  begins  to  be  compressed,  dangerous  cerebral 
symptoms  arise.  The  child  becomes  drowsy,  and  takes  less  notice  of 
objects.  Spasmodic  muscular  contractions  and  finally  convulsions  occur. 
The  pupils  act  feebly  or  irregularly  by  light,  or  one  is  more  dilated  than 
the  other.  Strabismus  also  occurs.  As  death  approaches,  eclamjisia, 
partial  or  general,  becomes  more  frequent,  and  is  succeeded  by  stupor 
from  which  the  patient  cannot  be  aroused. 

The  following  case,  which  I  copy  from  my  note-book,  is  an  example 
of  the  common  form  of  congenital  hydrocephalus.  It  will  give  an  idea 
of  the  ordinary  course  of  this  disease,  and  show  the  difficulty  which  Ave 
meet  Avith  in  its  treatment.  Female,  born  November  9,  1859,  Avith  the 
aid  of  forceps.  At  birth  the  fontanelles  were  unusually  large,  the 
cranial  bones  separated,  and  the  aspect  in  a  marked  degree  hydro- 
cephalic. She  nursed  at  first,  but,  the  mother's  milk  failing,  she  was 
afterward  bottle-fed.     At  the  age  of  four  months  her  head,  Avhich  had 


DIAGNOSIS.  447 

increased  faster  than  her  general  growth,  measured  from  one  auditory 
meatus  to  the  other,  over  the  vertex,  seventeen  inches ;  the  occipito- 
frontal circumference,  twenty-three  inches.  At  this  time  she  mani- 
fested considerable  intelligence,  being  able  to  distinguish  her  mother 
from  other  persons,  though  the  head  was  so  large  that  it  was  necessary 
to  support  it  constantly  on  a  pillow.  From  the  age  of  four  to  six 
months  the  operation  of  tapping  was  performed  six  times  with  a  small 
hydrocele  trocar,  bv  Prof.  Stephen  Smith,  at  a  point  near  the  coronal 
suture,  and  from  one  inch  to  one  inch  and  a  half  from  the  sagittal.  At 
each  operation  an  amount  of  fluid  varying  from  twelve  ounces  to  one 
pint  was  removed,  and  the  head  then  covered  with  strips  of  adhesive 
plaster,  so  as  to  form  a  complete  cap.  It  was  necessary,  however, 
within  the  twelve  hours  succeeding  each  operation,  to  loosen  the  dress- 
ing on  account  of  either  the  occurrence  of  convulsions  or  symptoms 
premonitory  of  them.  The  head,  within  a  week  subsequently  to  each 
operation,  regained  its  former  size,  and,  as  there  was  no  permanent 
benefit,  this  treatment  Avas  discontinued.  She  finally  died  of  entero- 
colitis at  the  age  of  ten  months  and  five  days. 

At  the  autopsy  the  distance  from  one  auditory  meatus  to  the  other 
was  twenty  and  a  quarter  inches;  the  occipito-frontal  circumference, 
twenty-six  and  a  quarter  inches.  The  anterior  fontanelle  measured 
antero-posteriorly  four  and  three-fourths  inches ;  transversely,  seven 
and  three-fourths  inches.  The  parietal  bones  were  separated  from  each 
other  to  the  distance  of  two  or  three  inches,  and  they  measured  in 
length  nine  and  one-half  inches. 

On  opening  the  cranial  cavity,  seven  pints,  by  measurement,  of 
transparent  fluid  escaped,  exposing  a  vast  open  space,  at  the  bottom  of 
which  were  the  parts  which  constitute  the  floor  of  the  ventricles,  some- 
what changed  in  sliape,  and  from  them,  on  either  side,  the  hemisphere 
was  spread  in  a  lamina,  so  as  to  cover  the  internal  surface  of  the  cranial 
bones.  The  laminie  near  the  base  of  the  brain  measured  in  thickness 
from  half  an  inch  to  one  inch,  and  they  gradually  became  thinner  on 
approaching  tlie  vertex,  at  which  point  the  brain-substance  was  exceed- 
ingly tliin,  so  as  to  be  scarcely  demonstrable. 

The  brain  had  its  normal  vascularity  and  consistence,  and  the  cere- 
bellum, medulla  oblongata,  tlie  base  of  the  brain,  and  cranial  nerves 
presented  their  usual  appearance.  On  finding  the  brain  together,  it 
had  the  size,  shape,  and  aspect  of  this  organ  in  its  ordinary  development. 
Nothing  unusual  was  observed  in  the  membranes  except  their  great  ex- 
pansion. The  above  case  corresponds  in  its  general  features  with  most 
cases  met  in  practice. 

D[A(iNO.si.s. — The  ordinary  form  of  congenital  hydrocephalus,  that 
in  which  the  li([uid  occupies  the  interior  of  the  brain,  can,  in  most 
cases,  be  readily  diagnosticated.  If  there  be  only  a  moderate  amount 
of  liquid,  it  may  be  confounded  with  hypertrophy  of  the  brain.  In 
liydroccphalus  there  are  commonly  more  rapid  growth  and  greater  expan- 
sion of  tlie  head  ;  moreover,  the  enlargement  occurs  equally  on  all  sides, 
while  in  hypertrophy,  though  all  parts  of  the  cranial  vaults  are  ex- 
pandeil,  tlie  enlarg(Mnent  is  more  at  the  vertex  than  elsewhere.  The 
hydrocephalic  head  yiehls  more  readily  to  pressure  than  the  hypertro- 


448  CONGENITAL    II  Y  D  R  O  C  E  P  II  A  L  U  S  . 

phied,  and  often  communicates  a  fluctuating  sensation  Moreover,  in 
the  ordinary  form  of  hydrocephalus,  the  chano;e  iix  the  axis  of  the  eyes 
described  above  is  an  important  diagnostic  sign.  In  rachitis  the  volume 
of  the  head  is  often  considerably  enlarged,  due  sometimes,  in  part  at 
least,  to  a  deposit  of  calcareous  matter  on  the  exterior  of  the  cranial 
bones.  The  differential  diagnosis  is  based  on  the  shape  of  the  head, 
round  in  one,  square  or  ^vitll  prominences  in  the  other,  on  palpation, 
direction  of  the  eyes,  etc.  The  smaller  the  amount  of  licpiid,  the  greater 
the  liability  to  error  of  diagnosis ;  but  if  the  amount  be  inconsiderable 
and  not  increasing,  little  treatment  is  required,  except  hygienic  and 
tonic,  which  is  also  proper  in  both  hypertrophy  and  rachitis.  If  the 
liquid  be  exterior  to  the  brain,  as  in  the  case  represented  on  page  445, 
diagnosis  may  be  difficult,  but  such  cases  are  infrequent. 

Prognosis. — In  the  majority  of  cases  this  is  unfavorable,  since  the 
secretion  of  liquid  usually  continues.  The  most  fixvorable  result  is  no 
increase,  or  but  slight,  in  the  quantity,  while  the  natural  growth  of  the 
infant  increases,  and  thus  the  disproportion  between  the  head  and  the 
rest  of  the  system  gradually  disappears.  Such  patients  may  live  to 
maturity,  and  have  tolerable  healtli,  and  they  may  engage  in  occupa- 
tions. But  ordinarily  in  cases  left  to  themselves,  and  even  in  a  large 
proportion  of  those  having  the  best  treatment,  while  the  quantity  of 
fluid  increases,  the  nutrition  of  the  body  and  limbs  becomes  moi'e  and 
more  deficient,  and  the  patient,  if  not  cut  off  by  an  intercurrent  disease, 
finally  succumbs  with  cerebral  symptoms  produced  by  pressure  of  the 
li([uid.  Probaldy  more  than  half  of  the  hydrocephalic  patients  die  be- 
fore the  close  of  the  second  year. 

Treatment. — We  may  attempt  to  diminish  the  quantity  of  fluid  by 
the  use  of  diuretics.  Digitalis,  squills,  nitrate  and  acetate  of  potassium, 
have  been  used.  The  most  efficient  diuretic  in  these  cases,  however,  is  the 
iodide  of  potassium.  Tliis  may  be  given  in  doses  of  one  to  two  grains 
every  two  hours  to  an  infant  of  three  months.  Constipntion,  if  present, 
should  be  relieved  by  an  occasional  purgative.  If  it  be  tolerated,  we  may 
partially  prevent  the  expansion  of  the  head  by  a  close-fitting  cap.  For 
this  purpose  strips  of  adhesive  plaster  about  one-third  of  an  inch  in 
width,  should  be  applied  so  as  to  cover  the  entire  head.  The  proper 
way  of  applying  these  is  as  follows :  First,  one  strip  from  each  mastoid 
process  to  the  outer  part  of  the  orbit  on  the  opposite  side ;  secondly, 
from  the  back  of  the  neck,  along  the  longitudinal  sinus,  to  the  root  of 
the  nose;  thirdly,  over  the  whole  head,  so  that  the  different  strips  will 
cross  each  other  at  the  vertex ;  and,  lastly,  a  strip  long  enough  to 
pass  three  times  around  the  head  should  be  applied,  passing  above  the 
eyebrows,  the  ears,  and  below  the  occipital  protuberance.  Too  tight 
an  application  should  be  avoided,  as  it  may  give  rise  to  ccmvulsions  or 
other  cerebral  symptoms.  If  the  cap  can  be  tolerated,  and  the  general 
health  bo  good,  the  prospect  is  more  favorable ;  but  usually,  from  the 
increase  in  the  quantity  of  fluid,  it  is  necessary  in  a  few  days  to  remove 
or  loosen  the  strips  in  order  to  pi*event  convulsions,  or,  which  is  prefer- 
able, to  diminish  the  size  of  the  head  and  relieve  the  pressure  by  tapping. 
In  56  cases  collected  by  Dr.  West  in  Avhich  tapping  was  employed,  four 
recovered.     The  operation  is  simple,  easily  performed,  devoid  of  danger, 


ACQUIRED    HYDROCEPHALUS.  449 

and  it  frequently  gives  temporary  relief.  It  should  therefore  be  recom- 
mended to  the  parents,  even  if  it  do  not  effect  a  cure.  .  It  should  be 
performed  by  a  very  small  trocar,  which  should  be  introduced  in  the 
coronal  suture,  about  an  inch  external  to  the  anterior  fontanelle.  A 
few  ounces  should  be  removed,  and  strips  of  adhesive  plaster  or  an 
elastic  skull  cap  applied.  In  a  few  days  the  operation  should  be  re- 
peated as  the  li([uid  increases.  It  is  important  to  maintain  compression 
of  the  skull  before  and  after  the  operation  (Treves).  Sometimes  a 
dozen  or  more  tappings  are  required  at  intervals  of  a  few  days  or  weeks, 
Avlien  the  secretion  may  come  to  a  standstill.  In  the  3Ied.  Qliir.  Trmis., 
1864,  a  case  is  related  in  Avhich  two  tappings  effected  a  cure,  but  so 
good  a  result  is  exceptional.  Iodine  injections  in  connection  with  tap- 
ping have  so  fur  not  produced  any  satisfactory  result.  Sir  James 
Paget'  relates  a  case  in  which  he  injected  ten  grains  of  iodine  and 
twenty  grains  of  iodide  of  potassium  in  one  ounce  of  water,  but  the 
child  died  of  convulsions  after  the  second  injection.  No  appreciable 
good  result  has  followed  the  use  of  irritating  or  sorbefacient  applica- 
tions to  the  head.  Nutritious  diet  and  attention  to  the  gen-eral  health 
are  requisite. 


CHAPTER  YIII. 

ACQUIRED  HYDROCEPHALUS. 

Hydrocephalus,  or  dropsy  of  the  brain,  may  also  occur  in  those 
who  at  birth  arc  Avell  formed  and  free  from  disease.  Pathologists  call 
this  acquired  hydrocephalus.  It  is  in  nearly  all  cases  the  result  of  dis- 
ease, which  is  located  sometimes  within  the  cranium,  but  often  in  other 
parts  of  the  system. 

Causes. — The  diseases  within  the  cranium  which  most  frequently 
produce  serous  effusion  are  the  meningeal  inilanimations,  both  simple 
and  tubercular,  tumors  or  other  causes  which  obstruct  the  venous  circu- 
lation, and  hemorrhagic  effusion  ending  in  the  formation  of  cysts.  Pro- 
longed passive  congestion  often  ends  in  transudation  of  serum  through 
the  coats  of  the  capillaries.  Therefore,  all  those  causes  of  congestion, 
except  such  as  have  a  transient  or  momentary  effect,  may  be  regarded 
as  causes  of  serous  effusion. 

Among  the  diseases  external  to  the  cranium  which  produce  serous 
effusif)n  within  or  upon  the  brain,  may  be  mentioned  retro))haryngeal 
abscess,  tuberculization  or  inflammation  of  the  bronchial  glands,  scarlet 
fever,  and  certain  affections  of  an  exhausting  nature,  especially  pro- 
tracted diarrhrcal  maladies.  In  at  least  five  cases  which  have  fallen 
uiiih'r  my  notice,  and  in  which  post-mortem  examinations  were  made, 
the  cause  was  enlarged  tubercular  bronchial  glands,  which,  by  pressure 

>  Medical  Titnca  and  Gazette,  18G0. 
29 


450  ACQUIRED    HYDROCEPHALUS. 

on  the  veiiffi  innominate,  so  retarded  the  flow  of  blood  from  the  brain 
as  to  cause  congestion  and  effusion.  The  causative  rehition  of  these 
glands  to  cerebral  congestion  is  more  fully  described  in  our  remarks  in 
reference  to  this  disease. 

Dropsy  of  the  brain  is  common  in  ]irotracted  infantile  diarrhoea,  as,  for 
example,  in  advanced  cases  of  intestinal  catarrh  of  the  summer  months 
in  the  cities.  It  is  preceded  and  accompanied  by  passive  congestion  of 
the  cerebral  veins  and  sinuses,  due  in  part  to  feebleness  of  circulation 
in  consequence  of  the  exhausted  state  of  the  patient,  and  in  part  to 
wasting  of  the  brain,  which  always  give  rise  to  more  or  less  passive 
congestion,  unless  in  young  infants,  in  whom  the  cranial  bones  become 
depressed  and  override  each  other.  Dropsy  of  the  brain,  resulting 
from  scarlet  fever,  and  that  peculiar  circumscribed  dropsy  which  results 
from  hemorrhao;ic  effusions,  are  described  elsewhere. 

A  few  cases  have  been  related  by  different  observers,  Abercrombie 
among  others,  in  which  dropsy  of  the  brain  seemed  to  be  essential. 
Nothing  abnormal  Avas  obsei'vecl,  with  the  exception  of  serous  effusion. 
But  the  reports  of  such  cases  are,  for  the  most  part,  meagre;  and,  as 
Barrier  has  well  said,  we  are  not  to  accept  such  cases  as  examples  of 
essential  dropsy  of  the  brain,  unless  the  post-mortem  inspection  be  so 
complete  as  to  render  it  certain  that  there  was  no  pathological  state 
which  might  cause  the  dropsy. 

Anatomical  Characters. — Acquired  hydrocephalus  usually  occurs 
after  the  cranial  bones  are  firmly  united,  and,  therefore,  the  shape  of 
the  head  is  not  materially  altered.  If  it  occur  at  any  early  age,  before 
there  is  free  union,  there  may  be  expansion  of  the  cranial  arch,  as  we 
sometimes  observe  in  the  circumscribed  hydrocephalus  resulting  from 
hemorrhage.  The  effusion  in  acquired  hydrocephalus  occurs  over  the 
surfoce  of  the  brain,  in  tlie  subarachnoid  space,  or  in  the  lateral  ven- 
tricles. In  the  dropsy  of  protracted  diarrhocal  maladies,  I  have  rarely 
failed  to  find  the  liquid  over  the  whole  superior  surface  of  tlie  brain  as 
well  as  at  its  base. 

The  quantity  of  fluid  in  this  disease  is  not  large.  In  the  majority 
of  cases  it  docs  not  exceed  four  ounces,  and  is  often  much  less.  It  is 
transparent,  or  it  has  a  slightly  yellowish  tinge.  The  membranes  of  the 
brain  sometimes  present  their  normal  appearance,  but  in  other  cases 
they  are  injected.  The  brain  itself,  in  some  instances,  has  an  injected 
appearance  from  passive  congestion  of  the  veins  and  capillaries ;  but  in 
others,  when  there  has  been  more  or  less  compression  of  the  brain,  there 
is  no  more  than  the  ordinary,  or  even  less  than  the  ordinary  vascularity, 
and  the  convolutions  are  somewhat  flattened. 

Symptoms. — The  symptoms  of  the  pathological  state  which  gives 
rise  to  the  dropsy,  precede  and  accompany  those  which  are  referable  to 
the  dropsy  itself.  The  dropsy  declares  itself  by  symptoms  which  are 
alarming  from  the  first. 

In  children  old  enough  to  speak,  or  manifest  intelligence,  there  may 
be  at  first  complaint  of  headache.  The  child  is  irritable,  its  mind  con- 
fused or  wandering  at  times,  or  there  is  actual  delirium.  After  a  time 
drowsiness  occurs.  The  head  seems  too  heavy  for  the  body,  and  is  buried 
in  the  pillow.     In  fatal  cases  the  features  become  pallid,   the    pupils 


SYMPTOMS.  451 

sluggish,  and  perception  and  consciousness  are  gradually  lost.  The 
child  lies  in  profound  sleep,  which  increases.  There  arc  now  often  con- 
vulsive movements  partial  or  general,  and  these  soon  end  in  coma,  in 
which  the  patient  dies. 

The  following  was  an  interesting  case  of  acquired  hydrocephalus,  which 
seemed  to  result  from  subacute  meningitis.  The  patient  was  seen  by 
several  physicians,  and  the  diagnosis  Avas  for  a  long  time  doubtful. 

Harry  K.  L.,  of  healthy  parentage,  was  well  till  the  summer  of  1876, 
when  he  was  nearly  at  the  close  of  his  third  year.  At  this  time  he  was 
observed  to  be  feverish  and  fretful  and  his  features  were  flushed  at  times. 
He  also  complained  almost  daily  of  pain  in  the  top  of  his  head,  which 
pain  was  intermittent,  and  these  attacks  of  headache  occurred  for  at  least 
six  months,  perhaps  longer.  There  had  been  no  backwardness  in  den- 
tition, and  no  symptoms  of  rachitis  or  struma,  and  his  nutrition  Avas 
good  even  after  the  commencement  of  the  present  malady. 

In  February  or  March,  1877,  his  stomach  became  irritable,  so  that 
he  vomited  often  during  the  following  months,  and  about  the  same  time 
he  began  to  lose  the  use  of  both  legs — a  progressive  paralysis — and  his 
bowels  became  constipated.  Both  urination  and  defecation  were  slug- 
gishly performed. 

In  July,  1877,  he  ceased  to  walk,  and  he  has  not  been  able  to  stand 
since. 

On  ]March  29,  1878,  the  following  records  were  made:  No  improve- 
ment, but  gradual  increase  of  most  of  the  symptoms;  lies  constantly; 
moves  his  limbs  slowly,  and  infrequently,  but  completely,  and  sensation 
appears  to  remain  in  all  of  them;  his  eyes  are  clear  and  pupils  mod- 
erately dilated,  but  without  vision — how  long 
his  sight  is  lost  is  not  known;  axis  of  eyes  not  Fig.  30 

depressed  or  otherwise  changed,  and  parallelism 
retained;  the  cranium,  which  during  tlie  first 
year  of  his  sickness  underwent  little  change, 
has  expanded  rapidly  during  the  last  six  months ; 
the  enlargement  is  most  marked  above  the  ears ; 
the  occipito-frontal  circumference  is  represented 
in  tlie  accompanying  diagram;  this  circumfer- 
ence measures  twenty-one  and  a  half  inches,  of 
which  nine  and  three-cjuarters  are  in  front  of 

ears,  and  eleven  and  one-third  inches  posterior  to  ears;  distance  over 
vertex  from  one  auditory  meatus  to  the  other,  fifteen  and  one-quarter 
inches.  The  anterior  fontanelle  is  observed  to  be  open,  though  small, 
the  diameter  being  about  one-fourth  or  one-third  of  an  inch;  it  is  not 
elevated,  and  the  surrounding  edge  of  bone  is  flexible. 

This  patient  lived  till  near  the  close  of  1880,  without  material  change 
in  symptoms,  and  with  moderate  but  progressive  increase  in  the  size  of 
the  head.  At  the  autopsy  measurements  Avere  again  made,  but  they 
have  been  mislaid.  The  eidargement  was  found  to  bo  due  to  the  pres- 
ence of  about  three  pints  of  straw-colonMl  serum  in  the  lateral  ventricles, 
whicli  had  been  changed  into  a  large  cavity.  There  was  nothing  to  in- 
dicate any  other  disease.  From  the  history  and  appearances  we  inferred 
that  the  hydrocephalus  had  been  due  to  a  mild  meningitis   occurring 


452  MENINGITIS. 

in  tlie  third  year.  The  appearance  and  state  of  the  oncephalon  -were 
precisely  like  those  in  ordinary  congenital  hydrocephalus. 

Prognosis. — Acquired  hydrocephalus  commonly  ends  unfavorably. 
The  prognosis  depends  not  only  on  the  quantity  of  licjuid,  but  on  the 
nature  of  the  cause.  If  the  cause  be  venous  obstruction  uithin  the 
cranium  or  thorax,  as  we  have  no  means  of  removing  it,  death  is  inevit- 
able. If  it  be  an  exhausting  disease,  as  entero-colitis  or  scarlet  fever, 
although  the  case  is  not  absolutely  hopeless,  the  prospect  is  still  unfavor- 
able. It  is  only  favorable  when  the  quantity  of  effused  fluid  is  small, 
the  system  not  much  reduced,  nnd  the  primary  disease  mild.  AVhen 
acquired  hydrocephalus  arises  from  meningeal  apoplexy,  the  case  is 
usually  chronic.  The  symptoms  and  termination  of  this  form  of  the  dis- 
ease are  very  similar  to  those  in  congenital  hydrocephalus. 

Treatment. — The  treatment  in  acquired  hydrocephalus  must  vary 
somewhat  in  different  cases,  according  to  the  nature  of  the  disease  on 
which  it  depends.  I  shall  indicate  the  treatment,  in  part  at  least,  in  the 
description  of  these  diseases.  Occasionally  the  condition  of  the  patient 
is  such  that  there  is  little  to  encourage  us  in  the  employment  of  any 
remedial  measures.  In  vigorous  children,  if  acquired  hydrocephalus 
occur  in  connection  with  symptoms  which  indicate  too  active  a  circula- 
tion, moderate  abstraction  of  blood  from  the  temples  at  an  early  period 
mav  be  useful,  but  cases  requiring  such  depletory  measures  are  rare. 
These  cases  re(|uire  cold  applications  to  the  head;  the  bowels  should  be 
opened,  and  derivatives  should  be  applied  to  the  feet  and  back  of  the 
neck. 

If  the  congestion  be  of  a  passive  character,  as  Avhen  the  circulation  is 
obstructed  by  tumors  or  otherwise,  benefit  may  still  be  derived  from 
cold  applications  to  the  head,  and  derivatives  to  other  parts.  In  most 
cases  of  suspected  dropsy  of  the  brain,  unless  the  patient  be  in  such  a 
hopeless  state  that  all  treatment  is  ol)viously  futile,  vesication  should  be 
produced  behind  the  ears.  I  prefer  cantharidal  collodion  for  this  pur- 
pose. In  addition  to  this  treatment,  diuretics  should  be  employed, 
unless  there  be  too  great  prostration,  or  the  course  of  the  disease  be  so 
rapid  that  no  benefit  can  result  in  conse(pience  of  the  tardy  action  of 
these  agents.  The  best  diuretics  are  the  acetate  of  potassium  and  iodide 
of  potassium. 


CIIAPTEK   IX. 

MENINGITIS,  TUBERCULAR  AND  NON-TUBEHCULAE. 

The  most  interesting  and  important  disease  of  the  cerebro-spinal 
system  in  early  life,  is  that  which  is  now  designated  meningitis.  It  is 
not  infrequent.  The  mortuary  statistics  of  this  city  show  that  it  is  the 
cause  of  death  in  from  one  in  twenty-five  to  one  in  fifty  of  the  entire 
number  of  deaths,  the  proportion  varying  somewhat  in  different  years. 


MENINGITIS.  453 

In  1768,  the  attention  of  the  profession  was  particuhirly  called  to 
this  disease  by  Dr.  Whytt,  of  Edinburgh.  This  observer,  and  the  path- 
ologists succeeding  him,  forming  their  opinion  of  meningitis  fi'om  its 
most  prominent  anatomical  character,  namely,  serous  effusion,  believed 
it  a  dropsy.  They  accordingly  designated  it  acute  hydrocephalus. 
During  the  last  forty  years  the  profession  have  come  to  regard  the  dis- 
ease as  inflammatory,  and  hence  the  name  by  "which  it  is  now  known, 
antl  which  is  believed  to  express  its  true  pathological  character. 

Sometimes  meningeal  inflammation  in  children  occurs  without  tuber- 
cles. In  other  instances  it  results  from  the  presence  of  tubercles,  and 
in  most,  if  not  in  all  such  patients,  there  are  tubercles  in  or  under  the 
meninires,  which  excite  the  inflammation  in  the  same  manner  as  in  the 
lungs  they  cause  pneumonitis  or  pleuritis.  Therefore  two  forms  of 
meningitis  are  recognized,  namely,  tubercular  and  non-tubercular. 

Prior  to  1868  1  had  preserved  records  of  forty-five  fatal  cases  of 
meningitis,  some  occurring  in  my  private  practice,  and  the  remainder  in 
institutions  of  this  city  Avith  which  I  have  been  connected.  Post- 
mortem examinations  were  made  and  recorded  in  thirteen  of  them. 
Twenty-five  were  under  the  age  of  one  year,  of  which  fifteen  were  ap' 
parently  well  when  the  meningitis  commenced,  belonging  for  the  most 
part  to  healthy  families ;  three  were  feeble  and  cachectic,  but  appar- 
ently without  tubercles ;  and  five  had  miliary  tubercles  in  various  organs, 
as  shown  by  post-mortem  examination.  The  condition  of  the  other  two 
as  regards  the  probable  presence  of  tubercles,  was  not  recorded. 

Of  the  twenty  who  were  over  the  age  of  one  year,  the  majority, 
namely,  thirteen,  presented  a  decidedly  cachectic  or  strumous  aspect 
before  the  meningitis  occurred,  and  a  considerable  number  had  symp- 
toms of  ])ulmonary  tubercles.  These  statistics,  as  far  as  tliey  go,  show 
that  non-tubercular  meningitis  predominates  under  the  age  of  one  year, 
and  I  may  add  eighteen  months,  while  over  that  age  the  tubercular 
cases  are  in  excess. 

M.  Bouchut,  speaking  in  refei'ence  to  tubercular  meningitis,  says  as 
follows :  "  Up  to  this  period  it  was  not  believed  that  this  disease  existed 
in  young  children,  for  no  mention  is  made  of  it  in  the  works  of  Denis 
and  Billard.  Still  its  existence  at  this  age  is,  nevertheless,  incon- 
testable. MM.  de  Blache,  Guersant,  llilliet  and  Barthez,  and  Barrier 
have  observed  several  examples  of  it,  and  I  have  collected  six  cases  of 
this  disease  in  the  practice  of  M.  Trousseau.  The  youngest  child  was 
oidy  three  montlis  old,  and  tlie  eldest  had  arrived  at  the  end  of  his 
second  year.  No  statistics  can  be  based  on  so  small  a  mnnber  of  facts; 
the  oidy  value  they  have  consists  in  their  overruling  an  opinion  falsely 
accredited  in  medical  science."  I  have  witnessed  the  post-mortem  of 
five  cases  of  tubercular  meningitis  occurring  in  children  under  the  age 
of  one  year,  as  is  seen  from  the  al)ove  statistics,  and  the  age  of  one  of 
these  was  oidy  four  months.  \n  two,  pei-hajis  1  should  say  three,  of  the 
five  the  presence  of  tubercles  in  the  meninges  was  not  ])ositively  demon- 
strated ;  but  in  all  of  the  five  cases  miliary  tubercles  were  present  in  the 
lungs  and  other  organs,  so  that  1  did  not  hesitate  to  consider  the  men- 
ingeal inflammation  of  a  tubercular  character. 

In  patients  over  the  age  of  eighteen  months,  although  the  })ro})ortion 


45J:  MENINGITIS. 

of  tubercular  to  non-tubercular  cases  is  larger  than  under  this  age,  the 
excess  is  not  so  great,  according  to  my  statistics,  as  the  remarks  of  some 
observers  lead  us  to  suppose.     There  can  be  no  accurate  statistics  of 
tubercular  meningitis  without  careful  post-mortem  examination  of  the 
state  of  the  brain  and  other  organs  in  each  supposed  case,  and  this  ex- 
amination sometimes  shows  the  meningitis  to  be  non-tubercular,  when 
the  symptoms  and  signs  had  indicated  its  tubercular  character.     As  an 
example,  may  be  mentioned  a  case  which  occurred  in  the  children's 
service  of  Charity  Hospital,  in  March,  1868.     The  infant  died  at  the 
age  of  twenty  months,  having  had  a  cough  of  moderate  severity  at  least 
three  weeks  before  death,  and  symptoms  of  meningitis  about  four  days. 
It  was  considerably  wasted,  and  was  supposed  to  have  tubcrcidosis.     At 
the  autopsy,  no  tubercles  were  found  in  any  part  of  the  body,  but  portions 
of  both  lungs  were  hepatized.     A  fibrinous  deposit,  varying  in  thick- 
ness, was  found  over  the  pons  Varolii,  the  optic  commissure,  along  the 
fissures  of  Sylvius,  over  the  superior  surface  of  the  anterior  half  and  also 
upon  the  superior  lobe  of  each  cerebral  hemisphere.     As  the  examina- 
tion  failed  to  discover  any   tubercles,  the  meningitis  was  considered 
non-tubercular.     Those  who  make  these  examinations,  failing  to  find 
tubercles  in  the  lungs  and  other  organs  in  which  they  usually  occur, 
should  examine  the  lymphatic  glands,  since  cheesy  glands  may  be  the 
cause  of  the  formation  of  tubercles  in  the  meninges,  while  the  organs  of 
the  trunk  remain  unaffected.     The  presence  of  cheesy  glands  in  the 
absence  of  visceral  tubercles,  and  with  granulations  upon  the  meninges, 
small,  covered  with  fibrin,  and  of  a  doubtful  character,  goes  far  toward 
establishing  the  tubercular  nature  of  the  meningitis.      Since  the  cases 
W'hich  furnished  the  above  statistics  were  observed,  now  more  than  thir- 
teen years,  I  have  been  led  by  a  more  extended  experience,  and  especi- 
ally by  the  observation  of  cases  in  the  New  York  Foundling  Asylum, , 
where  there  is  ample  material,  to    regard  not  only  the  presence  or' 
absence  of  tubercles,  but  also  of  caseous  substance,  as  the  proper  test 
of  the  form  of  meningitis.     Not  a  few  that  seem  at  first  to  have  non- 
tubercular  meningitis  will  be  found,  on  more  thorough  examination,  to 
have  caseous  substance  in  some  part,  the  result  of  a  preexisting  inflam- 
mation ;  and  if  we  regard  the  inilammation  of  tlie  meninges  occurring 
under  such  circumstances  as  tubercular,  the  relative  pro])ortion  of  tuber- 
cular  cases  will   be   considerably  augmented.     The    following    is   an 
example.     When  on  duty  in  the  asylum  in  August,  1881,  an  infixnt 
about  one  year  old  died  of  meningitis.     No  tubercles  were  observed  in 
the  fibrin  at  the  base  of  the  brain,  and  along  the  fissures  of  Sylvius  but 
one  inflammatory  nodule  (cerebritis)  as  large  as  a  chestnut,  with  sup- 
puration inside,  Avas  found  at  the  summit  of  one  hemisphere.     No  tuber- 
cles could  be  detected  in  any  of  the  organs  of  the  trunk,  unless  a  few 
whitish  spot<  in  the  spleen  were  of  this  nature,  but  the  bronchial  glands 
were  chetsy  and  softened,  and  the  middle  lobe  of  the  right  lung  also 
contained  cheesy  substance.     It  seemed  to  me  probable  that  some  of 
this  degenerated  ])roduct  taken  up  by  the  vessels  had  lodged  in  the 
meninges  and    ])roduced   the    tubercuhir  neoplasm    there,  which    was 
hidden  under  the  fibrin.     (See  article  Tuberculosis.) 

Age. — The  following  table  gives  the  age  in  meningitis,  tubercular 
and  non-tubtrcular,  in  forty-two  cases  in  my  collection : 


PATHOLOGICAL    AXATOMY.  455 

Cases.  Age. 

1 2\  weeks.     (Autopsy.) 

2  ........  2  months. 

20 From  3  to  12  months. 

10  .......         .  From  1  years  to  2  years. 

5  .......         .  From  2  years  to  5  years. 

4  .......         .  Over  5  years. 

42 

Rilliet  and  Barthez  have  also  published  statistics  of  the  age  in  men- 
ingitis. Their  cases  were  observed  chiefly  in  hospital  practice,  and  the 
result  is  somewhat  different. 

In  thirty-two  cases  of  non-tubercular  meningitis  observed  by  these 
authors,  eight  were  under  the  age  of  one  year,  six  from  tAvo  years  to 
five,  and  eighteen  over  the  age  of  five  years.  In  ninety-eight  cases  of 
tubercular  meningitis,  two  were  under  the  age  of  one  year,  fifty-one 
between  the  ages  of  one  year  and  five,  thirty-eight  between  the  ages  of 
five  years  and  ten,  and  seven  between  ten  and  fifteen  years. 

Pathological  Anatomy. — This  differs  considerably  in  different 
cases.  The  dura  mater  is  usually  unaffected  or  is  affected  secondarily. 
In  many  cases  it  retains  its  normal  appearance,  its  internal  surface 
remaining  smooth  and  polished,  while  in  others  it  is  more  or  less  in- 
jected, and  its  internal  surflice  dim  or  lustreless.  The  free  surface  of 
the  pia  mater,  formerly  designateil  the  visceral  arachnoid,  is  in  a  great 
part  of  its  extent  unchanged,  but  is  often  hypemcmic,  or  dry  and  cloudy, 
or  opaque,  over  the  seat  of  the  inflammation.  Exudation  docs  not  occur 
upon  the  free  surface  of  the  pia  mater,  however  intense  the  inflammation. 

In  meningitis,  tubercular  and  non-tubercular,  the  inflammatory 
action  occurs  in  the  pia  mater.  In  its  meshes,  or  underneath  them, 
those  lesions  result  wliich  characterize  the  disease,  and  to  Avhich  other 
lesions  are  secondary.  Tubercular  meningitis  is  most  frequently  basilar, 
or  is  basilar  chiefly  and  primarily,  although  the  inflammation  may 
extend  along  the  sides  of  the  hemispheres.  The  meningitis  is  ordi- 
narily most  intense  around  the  pons  Varolii  in  the  subarachnoid  space 
and  along  the  fissures  of  Sylvius,  for  the  tubercular  neoplasm  occurs 
cliielly  at  the  base  of  the  brain  and  along  the  vessels.  In  non-tuber- 
cidar  meningiti.s,  the  inflammation  may  also  occur  at  the  base.  It  may 
in  young  infants  be  quite  diffuse,  and  of  little  intensity  in  any  one 
place,  producing,  in  addition  to  hyper.iemia  of  the  pia  mater,  slight 
cloudiness  and  a  moderate  or  slight  escape  of  leucocytes  from  the  blood, 
these  (pus-cells)  being  perha])s  visil)le  only  inider  the  microscope.  In 
meningitis  due  to  extension  of  inllannnation  from  an  otitis  media,  the 
inflammatory  action  is  intense,  confined  to  the  portion  of  the  meninges 
nearest  the  ear,  and  is  often  attended  by  inflammation  of  the  adjoining 
brain-substance,  with  perhaps  tlic  formation  of  an  al>scess.  If  the  cause 
be  exposure  to  tliesuns  rays,  the  meningitis  is  at  the  summit  of  the  brain. 

The  exudation  of  fihrin  is  greatest  along  the  course  of  the  vessels, 
and  in  the  depressions  between  the  convolutions,  and  the  opacity  is 
most  marked  in  these  situations.  Pus,  when  present,  is  often  semi- 
solid, from  the  small  proportion  of  li(|uor  puris  which  it  contains,  even 
in  recent  ca.ses.  If  the  disease  have  continued  several  days,  the  lifpior 
j)uris  may  be  mostly  absorbed,  and   the  pus-cell  becoming  shrivelled, 


45(5  MENINGITIS. 

irreguliiv,  and  aggregated,  may  resemble  closely  the  cheesy  tran^forma 
tion  of  tubercle-cells. 

The  tibrinous  exudation  presents  features  of  interest.  It  does  not 
usually  attain  much  thickness,  but  by  its  opacity  it  conceals  from  view 
the  brain  underneath.  If  it  occur  in  the  fissures  of  Sylvius,  the  ante- 
rior and  middle  lobes  are  united  by  it.  It  is  usually  infiltrated  through 
the  substance  of  the  ])ia  mater.  Sometimes  little  masses  of  variable 
size,  often  not  as  large  as  a  pin's  head,  appear  at  the  point  of  inflamma- 
tion. These  masses  are  firm,  of  a  whitish  color,  or  a  light  yellow,  and 
their  number  varies  in  different  cases.  They  consist  of  a  firm,  homo- 
geneous substance,  containing  granular  matter,  and  cells  which  often 
bear  a  close  resemblance  to  tubercle-corpuscle,  but  are  distinct.  These 
corpuscular  bodies  are  plastic  nuclei  or  plastic  cells,  often  shrunken.  It 
is  seen,  then,  that  there  are  two  morbid  products  which  may  be  mis- 
taken for  tubercle :  one,  pus  which  has  been  in  great  measure  deprived 
of  its  liquid  element,  and  which  may  resemble  cheesy  tubercular  matter ; 
the  other,  plastic  nuclei  collected  in  little  bodies,  so  as  to  resemble  the 
ordinary  form  of  crude  tubercle.  I  once  carried  to  one  of  the  best  micro- 
scopists  and  pathologists  of  this  city  some  of  the  exudation  from  a  case 
of  meningitis,  the  cellular  element  in  which  could  not  readily  be  distin- 
guished from  shrunken  tubercle-corpuscles.  The  exudation  was  from  a 
child  two  years  and  eight  months  old,  with  g(jod  health  previously  to 
the  meningitis  ;  without  tubercles  in  any  part  of  the  body,  with  parents 
healthy,  and  with  no  predisposition  to  tubercular  disease.  The  micro- 
scopist,  not  knowing  the  history  of  the  case,  or  character  of  the  family, 
and  ignorant,  like  all  of  us  at  that  time,  of  the  true  tubercle  cell,  pro- 
nounced the  exudation  tubercular  after  a  careful  examination  with  tlie 
microscope.  Bouchut  says :  "The  whitish  miliary  granulations  which 
are  observed  on  the  surface  of  the  pia  mater  have  a  certain  consistency 
and  tenacity  which  render  them  difficult  to  tear  with  the  needles  used 
for  the  preparation  for  the  microscope.  These  bodies  are  formed:  1. 
Of  fibro-plastic  elements,  whether  nuclei  or  fusiform  fibres;  oval-shaped 
cells  are  generally  present,  but  not  always.  The  nuclei  are  oval  or 
spherical,  generally  very  small — that  is  to  say,  they  hardly  exceed  in 
diameter  0.008  mm.  to  0.009  mm.  The  presence  of  these  little  si)heri- 
cal  nuclei  must  be  insisted  on,  because,  with  a  less  power  than  550 
diameters,  it  Avould  be  sometimes  impossible  to  establish  the  differences 
which  separate  them  from  the  elements  of  tubercles;  the  fusiform  fibres 
are  small  and  rare.  2.  There  exists  a  considerable  quantity  of  amor- 
phous homogeneous  matter,  in  which  minute  granulations  are  scattered  ; 
it  is  very  dense,  and  keeps  the  other  elements  strongly  united  together,  so 
that  it  is  difficult  to  isolate  them  completely.  3.  Vessels  are  very  rarely 
observed ;  the  fibres  of  cellular  tissue  are  also  rare,  or  altogether  Avanting." 

There  being  two  microscopic  elements  which  are  distinct  from  tubercu- 
lar formations,  but  are  liable  to  be  mistaken  for  them,  namely,  shrivelled 
pus-cells  and  plastic  nuclei,  more  or  less  altered,  it  is  seen,  in  part  at 
least,  why  the  old  writers,  and  some  of  a  more  recent  date,  either  hold 
that  all  meningitis  is  tubercular,  or  that  there  are  comparatively  few 
non-tubercular  cases. 

On  the  other  hand,   there  are  cases  of   true  tubercular   meningitis 


PATHOLOGICAL    ANATOMY.  457 

which,  even  with  a  pretty  careful  microscopic  examination,  might  be, 
and  probably  often  have  been,  regarded  as  non-tubercular.  In  order  to 
an  understanding  of  this  subject,  I  may  be  pennitted  to  repeat  certain 
facts  already  stated  in  the  article  on  tuberculosis.  The  views  of  path- 
ologists in  reference  to  •\vliat  is  the  primary  form  of  tubercle,  and  what 
is  and  what  is  not  tubercular  matter,  have  recently  undergone  a  great 
change.  It  is  now  known  that  the  tubercle-cell  is  a  round,  pale,  slightly 
granular  cell,  identical  in  appearance  with  the  normal  cell  of  the  lym- 
pathic  glands,  being  on  the  average  somewhat  smaller  than  the  white 
corpuscle  of  the  blood ;  that  it  is  produced  mainly  from  the  nuclei  of 
the  connective  tissue  by  proliferation ;  that  it  is  vitalized  like  other  cells, 
and,  of  course,  has  functional  activity ;  that  the  true,  the  living  cell, 
is  found  only  in  the  so-called  gray,  semi-transparent  tubercle.  It  is 
furthennore  known  that  Avhat  has  heretofore  been  considered  the  tuber- 
cle-cell, namely,  the  irregular,  sometimes  angular,  sometimes  oval  cell — 
without,  indeed,  any  typical  fonn — may  be  a  dead,  shrivelled,  and  altered 
tubercle-cell,  or  a  dead,  shrivelled,  and  altered  pus  or  other  cell.  If, 
therefore,  such  cells  are  found  in  the  meshes  of  the  pia  mater,  Ave  cannot 
determine  from  the  microscope  their  true  character.  We  can  only  form 
our  opinion  in  reference  to  their  nature  from  coiTcomitant  circumstances, 
or  from  discovering  in  connection  with  them  the  true  tubercle-cell. 
Those  products  which  have  been  designated  crude  tubercle  and  tuber- 
cular inTiitration,  contain  these  shrivelled  cells,  or  shrivelled  nuclei ;  and 
they  may  have  a  tubei'cular  origin,  or,  on  the  other  hand,  an  inflamma- 
tory origin,  Avithout  either  the  tubercular  product  or  diathesis. 

In  the  tuberculosis  of  young  children  I  have  found  in  a  large  propor- 
tion of  cases  in  which  I  have  had  an  opportunity  to  make  post-mortem 
examinations,  miliary  tubercles  disseminated  through  the  lungs,  and  per- 
haps other  organs,  in  small  masses,  many  of  them  not  larger  than  a  pin's 
head,  and  some  occurring  as  mere  specks  scarcely  visible.  These  minute 
tubercular  foruiations  have  ordinarily  been  semi-transparent,  and  some- 
times even  transparent  like  minute  drops  of  Avater,  and  containing  the 
true  anJ  unchanged  tubercle-cell.  Now  if  in  such  a  case  meningitis 
occur,  Ave  mav  find  *^he  tubercle-cell  in  or  Avith  the  fibrin  at  the  base  of 
the  brain.  But  failure  to  find  it,  even  Avith  protracted  microscopic  ex- 
amination, does  not  prove  its  absence  from  this  locality,  for  I  consider 
it  almost  impossible  to  discover  in  the  midst  of  the  fibrinous  exudation 
such  minute  points  of  tubercular  matter  as  are  seen  in  the  lungs,  liA'er, 
or  elsewhere. 

The  pia  mater  is  often  finnly  adherent  to  the  brain  at  the  seat  of  in- 
flammation, so  that  on  raising  it  a  portion  of  the  brain  may  be  detached 
and  reinoveil  with  it.  The  extent  of  the  inlhimniation  varies  nnich  in 
difTerent  cases.  There  may  in  extreme  cases  be  pretty  general  inflam- 
mation of  the  pia  mater.  In  cases  of  such  extensive  meningitis,  the 
symptoms  are  usiuilly  severe  and  the  course  of  the  disease  ra])id. 
Thus,  in  the  mouth  of  April,  186(),  a  girl  eleven  years  of  ago,  in  the 
I'rotestant  Episcopal  Orphan  Asylum  of  this  city,  had  complaincil  occa- 
sion illy  of  dizziness,  but  Avas  otherAvise  in  good  health,  cheerful,  and 
with  excellent  appetite,  till  Thursday,  Avhen  she  Avas  affected  Avith  ver- 
tigo, more  persistent  than  previously,  and  Avith  headache.     At  2  v.  M. 


458  MENINGITIS. 

on  the  following  day  she  was  seized  with  general  convulsions,  and  con- 
tinued insensible  or  nearly  so,  Avith  occasional  convulsive  movements, 
till  Monday,  when  she  died  comatose.  The  pia  mater  at  the  vertex, 
sides,  and  base  of  the  brain  had  a  cloudy  appearance,  and  underneath 
it,  in  ])laces,  was  a  thick,  creamy  substance  in  small  quantity,  Avhich, 
examined  by  the  microscope,  pi'oved  to  be  pus,  the  largest  amount  being 
near  the  pons  Varolii.  There  was  no  tubercle  under  the  meninges  or 
elsewhere,  and  no  appreciable  fibrinous  exudation.  The  meningitis, 
though  of  brief  duration,  was  nearly  general. 

The  only  additional  lesions  noticed  were  moderate  congestion  of  the 
brain  and  an  increase  in  the  quantity  of  the  cerebro-spinal  fluid. 

If  the  disease  be  protracted  three  or  four  weeks,  which  is  rare,  or  even 
less  time,  the  exuded  substance  may  undergo  further  changes,  such  as 
occur  in  simple  exudations  in  other  parts  of  the  system.  Thus,  on  the 
30th  of  April,  1860,  we  made  the  post-mortem  examination  of  an  infant 
at  the  Nursery  and  Child's  Hospital,  Avho  had  symptoms  of  cerebral  dis- 
ease, it  was  stated  for  several  weeks,  but  the  exact  time  was  not  ascer- 
tained. Prominent  among  the  symptoms  referable  to  the  cerebro-spinal 
system  toward  the  close  of  life  were  the  hydrocephalic  cry  and  rigidity 
of  the  neck.  The  appearance  at  the  autopsy  was  remarkable.  The  an- 
terior half  of  the  brain  was  completely  encased  in  a  deposit  Avhich  had 
nearly  the  appearance  of  lard.  It  filled  the  fissures  of  Sylvius,  and 
appeared  slightly  on  the  anterior  aspect  of  the  cerebellum.  Examined 
under  the  microscope,  this  substance  Avas  found  to  contain  numerous 
cells,  among  Avhich  could  be  distinguished  some  resembling  pus-cells, 
but  nearly  all  had  undergone  more  or  less  fatty  degeneration.  Here 
and  there  Avas  seen  a  large  cell  containing  numerous  small  oil-globules, 
the  compound  granular  cell  of  pathologists. 

The  brain  itself  in  meningitis  is  usually  hyperoemic.  On  making  an 
incision  through  it,  red  points  are  seen  upon  the  cut  surface,  Avhicli  in- 
dicate the  seat  of  the  congested  vessels.  The  inflammation  rarely 
extends  to  the  Avails  of  the  A'entricles,  but  the  choroid  plexus  is  injected. 
In  exceptional  instances  pus  or  fibrin  is  found  in  the  lateral  ventricles. 
In  the  infant,  tAvo  and  a  half  Aveeks  old,  Avhose  case  has  already  been 
alluded  to,  about  two  ounces  of  purulent  fluid  escaped  on  opening  the 
left  ventricle.  A  small  amount  of  licpiid  of  a  similar  character  was  con- 
tained in  the  right  ventricle.  The  distention  of  the  lateral  ventricles 
Avith  serum  is  one  of  the  common  results  of  meningitis.  This  fluid  is 
clear  or  straAA'-colored,  or  it  is  turbid  in  consequence  of  being  mixed 
more  or  less  with  the  softened  brain-substance.  The  quantity  does  not 
exceed,  tAvo,  three,  or  four  ounces,  and  is  often  not  more  than  one  ounce 
or  an  omice  and  a  half.  Tiie  distention  of  the  tAvo  ventricles  is  ordin- 
arily uniform,  as  they  are  united  l)y  the  foramen  of  IMonro,  but  now 
and  then  one  ventricle  is  found  more  distended  than  the  other.  If  there 
be  considerable  effusion,  the  brain  is  compressed  and  the  conA'olutions 
have  a  flattened  appearance,  unless  the  cranial  bones  are  still  separated 
so  as  to  yield  to  the  pressure.  If  the  sutures  and  fontanelles  be  open 
the  cranial  arch  is  expanded,  souictimes  quite  perceptibly  to  the  eye. 
From  the  same  cause  the  anterior  fontanelle,  if  open,  is  elevated.  The 
foramen  of  Monro  is  enlarged  according  to  the  amount  of  effusion,  and 


CAUSES.  4:59 

the  portions  of  the  brain  which  separate  the  ventricles  are  sometimes 
lacerated.  In  many  cases  the  cerebral  substance  sui-rounding  the  lateral 
ventricles  is  softened.  The  softening  is  found  in  all  degrees,  from  the 
least  appreciable  deviation  from  the  normal  consistence  to  a  state  of 
diffluenee,  so  that  the  brain  presents  the  appearance  of  cream.  Hypo- 
theses have  been  advanced  to  explain  the  cause  of  this  change  in  consis- 
tence, which  are  not  entirely  satisfactory.  Whatever  the  explanation, 
the  fact  is  attested  by  all  observers,  though  there  are  exceptional  cases. 
Thus  Dr.  West  has  records  of  the  condition  of  the  brain  in  fifty-nine 
cases,  in  thirty-seven  of  Avhich  there  Avas  considerable  softening,  and  in 
the  remaining  twenty-two  the  consistence  Avas  normal. 

Since  a  majority  of  the  cases  of  meningitis  in  children  are  basilar, 
and  portions  of  all  the  cerebral  nerves  lie  at  the  base  of  the  brain,  it  is 
easy  to  understand  why  the  functions  of  these  nerves  are  so  seriously 
impaired  in  this  disease.  .Compression  of  these  nerves,  or  extension  of 
intlainmation  to  their  sheaths,  aftbrds  explanation  of  many  of  the  symp- 
toms, as  the  sighing  respiration,  abnormalities  of  the  eye,  etc. 

Although  the  aljove  remarks  relating  to  the  anatomical  characters  of 
meningitis  are  applicable  to  a  large  majority  of  the  cases,  I  must  confess 
that  1  have  sometimes  been  disappointed  at  th'e  autopsies  of  young  in- 
fants who  died  with  all  the  symptoms  of  meningitis  in  not  finding  more 
lesions.  IModerate  hyperemia  of  the  pia  mater,  its  slight  opacity  or 
cloudiness  at  the  base  of  the  brain  or  elsewhere,  with  the  presence  of  a 
few  wandering  white  corpuscles,  without  any  fibrinous  exudaticm,  with 
no  increase  of  liquid  external  to  tlie  brain,  but  a  considerable  increase 
of  it  in  the  lateral  ventricles,  and  hyperaemia  of  the  choroid  plexus,  with 
nearly  natural  appearance  and  consistence  of  the  brain,  have  in  some 
instances  been  the  only  lesions  when  I  had  expected  to  find  marked 
anatomical  changes. 

I  am  fully  convinced  from  my  own  observations  that,  in  some  instances, 
physicians  who  supposed  that  they  were  treating  tubercular  meningitis, 
and  at  the  autopsies  discovered  within  the  cranium  tubercles,  A\nthout 
any  inflammatory  lesion,  but  with  a  larger  increase  of  the  cerebro-spinal 
licjuid,  have  been  treating  cases  in  which  in  addition  to  the  meningeal 
tubercles,  Avhicii  Avere  latent,  the  bronchial  glands  Avere  tubercular  and 
cheesy,  so  that  by  their  increased  size  they  compressed  tiie  voiiio  in- 
nominatie  Avithin  the  thorax,  thus  i)reventing  the  free  fioAV  of  blood  from 
the  brain,  and  causing,  as  I  have  elsewhere  stated,  cerebral  and  menin- 
geal congestion,  Avith  more  or  less  transudation  of  serum,  but  Avith  no 
meningitis. 

Causes. — The  causes  of  non-tubercular  meningitis  are  not  fully  ascer- 
tained. Active  cerebral  congestion  frecjuently  occurring,  however  pro- 
duced, appears  to  be  one  of  the  common  causes  in  young  infants.  In 
at  least  three  instances  I  have  known  meningitis  occur  in  infants  be- 
tween the  ages  of  four  and  eight  months,  after  severe  and  protracted 
bronchitis,  Avhich  had  ])een  attended  Avith  the  usual  heat  of  hea<l.  The 
disappearance  of  erujitions  upon  the  scalp,  at  or  immediately  before  the 
commencement  of  the  meningitis,  has  also  been  observed.  I  have  Avit- 
ne.ssed  it  at  the  connnencement  of  non-tubercular  meningitis,  as  avcII  as 
of  meningitis  Avhich,  if  not  tubercular,  occurred  at  least  in  a  decidedly 
scrofulous  state  of  system. 


460  MENINGITIS. 

The  direct  effect  of  the  solar  rays  upon  the  head,  and  the  prolonged 
action  of  a  high  atmospheric  temperature,  even  ■without  direct  exposure 
of  the  head  to  the  sun,  are  common  causes  during  the  summer  months 
in  New  York  City.  I  once  attended  a  child  with  this  disease  who  had 
been  mitch  exposed  bareheaded  to  the  direct  rays  of  the  sun  in  August 
and  September,  and  at  his  death,  which  occurred  toward  the  close  of 
the  hot  Weather,  found  hypers^mia,  opacity,  and  fil)rinous  exudation  in 
the  pia  mater  at  the  summit  of  the  brain,  while  the  base  of  the  brain 
seemed  nearly  or  quite  normal. 

Dr.  Soltmann,^  of  Breslau,  reports  three  cases,  in  which  intense  cere- 
bral hyperiigmia,  and  probably  meningitis,  occurred  from  solar  heat.  In 
all  three  children  the  attack  was  sudden,  the  febrile  movement  and  heat 
of  head  intense,  and  the  progress  ra])id.  Tlie  first  had  convulsions,  the 
second  automatic  movements,  and  the  third,  the  oldest,  aged  four  years, 
when  able  to  speak,  complained  of  violent  headache. 

The  statistics  of  New  York  City  show  that  congestive  and  inflamma- 
tory maladies  of  the  brain  and  its  covering  are  more  common  during 
July  and  August,  which  are  the  months  of  maximum  atmospheric  heat, 
than  in  other  months  of  the  year.  For  example,  in  July  and  August, 
1875,  one  hundred  and  sixty-seven  died  of  these  maladies,  or  one  in 
every  nine  and  eight-tenths  who  died  from  local  disease,  while  during 
the  entire  year  only  seven  hundred  and  ten  died  from  the  same,  or  one 
in  evei'y  fifteen  who  perished  from  local  diseases. 

July,  1H7G,  in  New  York  City,  was  characterized  by  excessive  and 
long-continued  atmospheric  heat,  the  temperature  of  the  Central  Park 
Observatory  in  the  shade  never  falling  below  61°,  though  never  above 
98^,  and  having  a  mean  of  82.9°  There  was  also  unusual  dryness  of 
the  atmosphere,  since  during  the  entire  month  prior  to  July  30th,  there 
were  only  fourteen  hours  of  rain,  with  a  rainfall  of  0.77  of  an  inch,  and 
the  average  atmospheric  humidity  was  represented  by  65,  saturation 
being  denoted  by  100.  During  this  month  I  treated  in  my  private 
practice  four  fatal  cases,  all  between  the  ages  of  two  and  seven  years, 
Avhich  I  diagnosticated  meningitis,  none  of  them  presenting  any  symp- 
toms of  otitis  or  tuberculosis.  It  would  seem  that  the  atmospheric  heat 
had  much  to  do  with  the  development  of  the  disease  in  these  cases.  One 
died  in  two  days,  but  in  the  others  there  was  the  usual  duration. 

A  not  infrequent  cause,  especially  among  the  strumous  families  of 
cities,  is  otitis  media,  and  caries  of  the  petrous  portion  of  the  tempo- 
ral bone,  the  inflammation  extending  to  the  meninges.  Since  tuber- 
cular meningitis  is  due  to  the  irritating  effect  of  tubercles  in  or  under 
the  pia  mater,  it  usually  occui'S  Avhere  tubercles  are  most  abundantly 
developed,  that  is,  at  tlie  base  of  the  brain,  and  along  the  course  of  the 
vessels  in  the  inter-gyral  spaces.  Tlie  inflammation  is  commonly 
excited  when  they  are  still  small,  even  minute. 

Premonitory  Stage. — Meningitis  is  usually  preceded  by  symptoms 
which,  if  rightly  interpreted,  are  of  the  greatest  value.  In  most  cases 
of  this  malady  which  I  have  seen,  there  Avas  a  prodromic  period,  vary- 
ing from  a  few  days  to  several  weeks.     Tlie  symptoms  of  this  period 

^  Jahrbucli  f.  Kiiidurkrank.  fur  October,  1875. 


SYMPTOMS.  4C1 

are  obscure,  and  are  liable  to  be  mistaken  for  those  of  other  and  distinct 
aftections. 

The  child  in  whom  meningitis  is  approaching  loses  his  accustomed 
vivacity  and  cheerfulness.  He  has  a  melancholy  and  subdued  appear- 
ance, being  quiet  for  a  few  minutes,  and  then  fretful,  without  apparent 
causes.  He  can  sometimes  be  amused  by  his  playthings  or  comi)anions 
for  a  brief  period,  when  he  turns  from  them  with  evident  displeasure. 
Unexpected  and  loud  noises  and  bright  lights  are  evidently  painful.  If 
old  enough  to  describe  his  sensations,  he  complains  of  transient  dizzi- 
ness, and  at  other  times  of  headache.  His  ill-humor,  if  his  wishes  are 
not  immediately  gratified,  or  if  they  are  denied,  is  often  scarcely  endur- 
able on  the  part  of  friends,  who  are  ignorant  of  the  cause.  There  is 
great  difference,  however,  in  diiferent  cases,  as  regards  this  symptom. 
Some  are  inclined  to  be  taciturn  and  quiet,  while  others  are  almost  con- 
stantly fretting.  The  appetite  is  capricious ;  at  one  time  it  is  pretty 
good,  at  another  it  is  poor  or  even  entirely  lost.  The  patient  may  take 
a  few  mouthfuls  of  food,  or,  if  an  infant,  nurse  for  a  moment,  when  his 
hunger  appears  satisfied,  and  ho  will  take  nothing  more.  The  bowels 
are  regular  or  inclined  to  constipation.  The  pulse  is  natural,  or  it  has 
times  of  acceleration,  especially  in  the  latter  parf  of  the  day  and  toward 
the  close  of  the  premonitory  stage.  Tlie  duratio}!  of  this  stage  is  very 
different  in  diiferent  cases.  Upon  an  average  it  is  perhaps  about  two 
weeks,  but  it  is  often  longer.  In  tubercular  meningitis  the  symptoms, 
both  during  the  infiammation  and  previously,  are  often  complicated  by 
those  which  arise  from  tubercles  in  other  parts  of  the  system. 

Unless  the  prodromic  period  be  of  short  duration,  the  effect  of  imper- 
fect nutrition  is  obvious  before  it  closes.  The  flesh  becomes  soft  and 
flabby,  or  there  is  emaciation,  though  generally  slight.  The  patient 
loses  his  strencrth,  becomin<x  less  able  to  stand  or  to  walk,  and  more 
easily  fatigued.  Occasionally,  especially  in  the  non-t4il)ercular  form, 
premonitory  symptoms  are  absent,  or  are  slight  and  of  short  duration. 

SymptOxMS. — Dr.  Whytt,  living  in  the  last  century,  when  the  ten- 
dency was  toward  refinement  rather  than  simplicity  in  classification, 
divided  meningitis  into  three  stages,  according  to  the  symptoms,  especi- 
ally the  ])ulse.  Many  subsequent  writers,  foUowing  AVhytt's  cxamjile, 
have  recognized  three  stages,  based  not  upon  the  anatomical  chai-actei"s 
of  the  disease,  but  upon  the  succession  of  symptoms.  Such  division  of 
meningitis  is  in  great  measure  arbitrary,  since  in  one  case  the  same 
symptoms  occur  at  an  earlier  period  than  in  another. 

When  the  premonitory  stage  has  passed,  and  inflammation  is  devel- 
oped, soinr;  of  the  symptouis  which  were  previously  present  remain  and 
are  intensified,  and  other  new  and  more  cliaracteristic  symptoms  appear, 
'i'here  are  now  fewer  intervals  of  apparent  improvement.  The  chihl 
is  quiet,  often  lying  with  Ids  eyes  shut.  If  aroused,  he  has  a  wild  ex- 
pression of  the  face,  ami  is  irritated  by  attempts  to  engage  his  attention 
or  amuse  iiim.  He  rarely  smiles,  or  takes  his  playthings,  or  he  notices 
them  for  a  moment,  when  he  turns  awav  with  disgust.  During  sleep 
there  is  often  at  first  a  ])laciil  expression  of  countenance,  but  when 
aroused  lie  has  the  aspect  of  real  sickness;  the  eyebrows  are  sometimes 
contracted',  as  if  from  headache;  the  features  wear  a  melancholy  look, 


462  -AI  E  N  1  N  G  I T 1 S . 

and  are  turned  a'way  to  avoid  the  gaze  of  the  observer  or  to  slmn  the 
light.  If  the  anterior  fontanelle  be  open,  it  is  observed  to  be  prominent 
and  ])ulsating  forcibly.  If  consciousness  be  not  lost,  and  the  patient  l)e 
of  suiKcicnt  age,  he  complains  of  headache,  or  of  pain  in  some  part  of 
tiie  body.  The  tongue  is  moist,  and  covered  with  a  light  fur;  the  ap- 
petite is  lost  or  poor;  there  is  seldou:  much  thirst;  more  or  less  nausea 
and  constipation  are  present.  As  the  inllammation  continues,  and 
usually  Avithin  three  or  four  days  from  its  commencement,  symptoms 
arise  which  dispel  all  doubts,  if  there  were  any,  as  to  the  nature  of  the 
disease.  The  vital  powers  are  now  evidently  beginning  to  yield.  The 
surface  generally  is  more  pallid,  and  there  is  the  curious  phenomenon 
of  the  sudden  appearance,  and,  after  some  minutes,  disappearance,  of 
spots  or  patches,  or  even  streaks  of  active  congestion  upon  the  face, 
forehead,  or  the  ears.  These,  having  a  bright  red  color,  contrast 
strongly  Avith  the  general  pallor.  Ordinarily  they  are  irregularly  cir- 
cular or  oval,  and  from  one  inch  to  an  inch  and  a  half  in  diameter.  A 
red  sjwt  or  streak  is  also  produced  if  the  finger  be  pressed  upon  the 
surface  or  draAvn  forcibly  across  it.  It  continues  a  few  minutes  and 
then  gradually  fades.  Trousseau  calls  attention  to  this  fact  as  a  diag- 
nostic sign. 

Another  curious  phenomenon  is  the  variation  in  temperature.  The 
face  and  limbs  at  one  time  feel  quite  cool,  and  after  some  minutes,  with- 
out any  excitement  or  other  appreciable  cause,  the  temperature  rises,  so 
that  the  surface  is  Avarm  to  the  touch. 

Consciousness,  in  severe  cases,  may  be  lost  at  an  early  period.  On 
the  other  hand,  I  have  known  it  in  a  case  of  moderate  severity  to  remain, 
though  partially  obscured,  till  within  twenty-four  or  thirty-six  hours  of 
deatli.  The  patient  Avill  usually  open  his  mouth  for  drinks  Avhich  are 
placed  to  his  lip,  Avhen  there  is  no  other  evidence  of  intelligence,  and 
when  sight  and  hearing  are  evidently  lost. 

The  loss  of  the  senses  constitutes  an  interesting  but  melancholy  fea- 
ture of  the  disease.  Among  the  first  unequivocal  symptoms,  and  fre- 
quently the  very  first,  are  such  as  pertain  to  the  eye.  This  organ 
should  be  Avatched  from  day  to  day  when  the  diagnosis  is  uncertain. 
Deviation  from  its  normal  state  affords  evidence  of  meningitis.  The 
pupils  are  seen  to  dilate  or  contract  sluggishly  by  variations  in  the  in- 
tensity of  the  light,  or  they  are  not  of  the  same  size  Avith  those  of  another 
individual  to  Avhom  the  same  amount  of  light  is  admitted.  Sometimes 
the  first  perceptible  deviation  from  the  normal  state  is  an  inequality  in 
the  size  of  the  pupils;  while  in  others  oscillation  of  the  iris  is  observed. 
Later,  Avhen  convulsions  have  occurred,  the  parallelism  of  the  eyes  is 
lost.  After  effusion  has  taken  place,  the  pupils  are  commonly  dilated. 
As  death  approaches,  the  eyes  become  bleared,  and  a  puriform  secretion 
collects  in  the  inner  angle  of  the  eye  and  between  the  eyelids.  This 
secretion  is  not  abundant,  but  it  is  sometimes  sufficient  to  unite  the  lids. 
The  sense  of  hearing  is  probably  lost  as  soon,  or  nearly  as  soon,  as  that  of 
sight,  but  the  sense  of  touch  continues  longer.  The  tongue  is  covered  with 
a  moist  fur,  unless  near  the  close  of  life,  when  it  is  sometimes  dry.  The 
appetite  is  gradually  lost,  but  often  drinks  are  taken  Avith  apparent  relish, 
even  Avhen  there  is  no  other  evidence  of  consciousness.     There  are  two 


SYMPTOMS.  463 

symptoms  pertaining  to  the  digestive  system  which  are  rarefy  absent, 
and  which  possess  great  diagnostic  value;  one  is  vomiting,  the  other 
constipation.  In  some  patients,  irritability  of  stomach  begins  at  so  early 
a  period  that  it  is  really  prodromic;  it  is  rarely  absent.  Barrier  col- 
lected the  records  of  eighty  patients  with  meningitis,  and  in  seventy-five 
of  these  this  symptom  was  present.  It  is  due  to  the  intimate  relation 
existing  between  the  stomach  and  brain,  through  the  ganglionic  sys- 
tem of  nerves.  The  vomiting  occurs  Avithout  effort,  and  usually  at 
intervals,  for  several  days.  It  is  a  sudden  ejection  of  the  contents  of 
the  stomach,  apparently  without  preceding  or  subsequent  nausea.  It 
contrasts,  therefore,  with  the  vomiting  due  to  an  emetic,  which  is  attended 
by  distressing  symptoms.  With  some  it  occurs  frequently,  with  others 
not  moi'e  than  two  or  three  times  daily.  Commencing  in  the  first  stages 
of  meningitis,  or  even  prior  to  it,  it  occurs  less  often  as  the  drowsiness 
becomes  more  profound,  and  finally  ceases.  Constipation  is  also  present, 
usually  from  the  commencement  of  the  meningitis.  It  is  one  of  the 
most  consta^nt  and  persistent  symptoms,  continuing  through  the  entire 
sickness,  unless  relieved  by  medicine,  or  unless  there  be  a  coexisting 
diarrhoeal  affection.  Often,  when  diarrhoea  precedes  the  meningitis,  it 
ceases  the  moment  the  latter  commences.  The  Constipation  in  this  dis- 
ease is  easily  overcome  by  purgatives.  Several  writers  speak  of  retrac- 
tion of  the  abdomen  as  a  sign  of  meningitis.  A  hollow  or  sunken  ap- 
pearance of  the  abdomen,  according  to  Golis,  aids  in  distinguishing 
meningitis  from  fever.  The  anterior  abdominal  wall  approaches  the 
spine,  so  that  the  pulsations  of  the  abdominal  lorta  are  distinctly  felt. 
Rilliet  and  Barthez,  who  have  rarely  observeo  this  retraction  except  in 
cerebral  diseases,  attribute  it  to  the  state  of  the  intestines  rather  than  to 
the  action  of  the  abdominal  muscles. 

The  i)ulse  in  the  first  stages  of  meningitis  is  accelerated,  or  it  is  nearly 
natural  during  certain  hours  and  afterward  accelerated.  When  the  dis- 
ease has  continued  a  few  days,  often  not  more  than  three  or  four,  the 
pulse  undergoes  a  marked  change.  It  becomes  slower,  and  at  the  same 
time  irregular.  The  irregularity  usually  consists  in  an  intcrmittence 
of  the  pulse  after  each  six  or  eight  beats.  Sometimes  the  force  of  the 
pulse  varies,  so  that  a  feeble  pulsation  is  succeeded  by  one  of  greater 
volume  and  strength.  The  decrease  in  the  frequency  of  the  pulse 
cannot  fail  to  arrest  attention.  From  110  or  120  beats  per  minu*:e  in 
the  first  stage  of  the  inflammation  it  often  descends  to  a  frequency  even 
less  than  the  normal  adult  pulse.  At  an  advanced  period,  as  death 
approaches,  the  pulse  again  becomes  accelerated  and  feeble. 

The  change  in  respiration  is  as  decided  as  that  of  the  pulse.  In  the 
beginning  of  the  meningitis  respiration  is  sometimes  moderately  aoceler- 
ated,  but  in  other  cases  it  is  natural.  When  the  disease  has  continued 
a  few  days,  the  time  usually  varying  from  three  or  four  to  more  than  a 
week,  a  marked  alteration  occurs  in  the  respiratory  movements.  Their 
rhythm,  like  that  of  the  pulse,  is  changed.  The  breathing  is  irregular, 
intermittent,  and  accompanied  by  sighs.  The  change  in  |)ulse  and  res- 
piration corres[)ond3  with  the  1<jss  of  consciousness,  and  shows  that  the 
brain  is  becoming  seriously  involved. 

When  the  pulse  and  respiration  undergo  the  changes  which  liave  beer. 


464  MENINGITIS. 

described,  another  prominent  and  grave  cerebral  symptom  is  often  pres- 
ent, namely,  convulsions.  Its  occurrence  diminishes  greatly  the  prospect 
of  a  favorable  issue.  The  severity  and  extent  of  the  convulsive  move- 
ments vary  in  different  cases.  They  may  be  partial  or  general.  Their 
duration  is  often  brief,  but  they  recur  three  or  four  times  through  the 
dav-  They  are  preceded  by  cephalalgia  in  those  old  enough  to  express 
their  sensations,  and  often  by  droAvsiness.  Each  convulsive  attack  ends 
in  still  ojreater  drowsiness. 

AVith  this  group  of  symptoms  another  should  be  mentioned.  I  refer 
to  the  hydrocephalic  cry.  At  intervals  the  patient,  -without  being  dis- 
turbed, ;ind  without  any  change  in  symptoms,  utters  a  scream  or  sharp 
cry,  and  immediately  relapses  into  his  former  state.  This  cry  is  more 
common  in  the  commencement  of  the  meningitis  than  subsequently,  and 
in  many  it  is  absent  or  is  not  a  marked  symptom.  The  glandular 
system  participates  in  the  general  loss  or  derangement  of  function. 
Tears  are  seldom  shed,  even  when  the  child  is  much  irritated,  and  the 
urinary  secretion  is  diminished,  The  small  amount  of  urine  ])assed 
sustains  an  important  relation  to  the  j^rogross  of  the  disease  and  the 
therapeutics. 

The  patient  usually  lingers  several  days  after  the  pulse  and  respira- 
tion are  changed  in  the  manner  stated.  The  drowsiness  becomes  more 
profound,  tiie  vomiting  ceases,  as  well  as  the  convulsive  attacks,  and 
sensation  and  consciousness  are  entirely  lost.  But  even  in  this  state, 
if  nutriment  and  stimulants  be  administered  with  regularity,  the  child 
often  lives  several  days  longer  than  appeared  possible.  At  length  in- 
creasing feebleness  and  rapidity  of  jmlse  and  coldness  of  the  face  and  limbs 
indicate  the  near  approach  of  death,  which  occurs  in  a  state  of  coma. 

The  symptoms  described  above  are  such  as  we  observe  in  ordinary 
cases  of  meningitis,  and  in  the  order  which  I  have  indicated.  But  he 
will  be  disappointed  who  expects  that  the  above  descrif  iion  will  apply 
to  all  cases. 

Meningitis  may  be  so  violent  and  rapid  that  both  the  character  and 
succession  of  symptoms  are  different  from  those  which  have  been  stated. 
Thus,  I  have  related  the  case  of  a  girl,  who,  with  no  prodromic  symp- 
toms excepting  occasional  dizziness  and  slight  headache,  was  taken  sick 
on  Thui'sday,  had  convulsions  on  Friday,  and  from  this  ti-ine  continued 
either  in  convulsions  ar  coma  till  lier  death  on  Monday.  Again,  even 
in  cases  of  the  usual  duration  and  anatomical  character,  some  of  the 
most  prominent  symptoms  upon  which  we  rely  for  diagnosis  may  be 
lackini:.     The  following  was  a  case  of  this  kind: 

Cask. — On  the  5th  of  April,  1802,  I  was  asked  to  see  a  boy  two  years 
and  eight  m<mths  old,  of  healthy  i)arentage,  and  who,  during  the  preced- 
ing vear,  had  been  in  uniform  good  health,  but  previously  had  had  two 
or  three  severe  attacks  of  sickness.  His  head  was  unusually  large,  and 
whenever  much  indisposed  he  often  had  symptoms  ))remonitory  of  ccmvul- 
sions,  which  Avero  always,  however,  prevented. 

One  night,  in  the  latter  part  of  March,  his  parents  noticed  that  his 
sleep  was  restless,  but  on  the  following  day  he  seemed  entirely  well,  and 
the  restlessness  at  nijrht  was  attributed  to  a  late  and  hearty  supper.  On 
succeeding  nights,  however,  he  was  restless,  and,  when  questioned,  com- 


SYMPTOMS.  465 

plained  of  pain  in  the  abdomen.  In  a  few  days  he  was  observed  to  be 
drooping  in  the  daytime,  and  liis  appetite  was  not  quite  so  good  as  pre- 
viously." He  had  continued  in  this  way  about  a  week  when  my  first  visit 
was  made. 

The  abdominal  pain  had  at  this  time  become  more  ci:)nstant,  but  was 
never  severe  or  accompanied  by  moaning.  When  asked  where  he  felt 
sick,  he  placed  his  hand  upon  the  epigastrium,  pressure  upon  which  was 
sometimes  tolerated,  but  at  otlier  times  painful.  The  follov  ing  symp- 
toms were  noted  :  tongue  slightly  furred,  anorexia,  thirst,  constipation, 
scantiness  of  urine,  no  headache  or  unusual  heat  of  head  during  any  part 
of  his  sickness.  He  vomited  at  intervals  from  about  the  7th  to  the  10th 
of  April,  when  the  irritability  of  stomach  ceased,  and  there  was  no  return 
of  this  symptom. 

About  April  7th,  the  respiration  was  first  observed  to  be  irregular  and 
sighing,  and  the  pulse  intermittent.  These  symptoms,  .so  tardily  devel- 
oped, were  the  first  which  indicated  cerebral  disease.  He  now  lay  most 
of  the  time  in  bed,  with  eyes  closed,  surface  commonly  pallid,  with  occa- 
sional rose-colored  spots  or  patches  upon  the  cheek  or  forehead.  The 
pupils  responded  to  light  in  the  usual  manner  till  near  the  close  of  life, 
but  l)right  lights  were  painful :  the  last  two  or  three  days  of  his  life  the 
left  pujnl  was  more  dilated  than  the  right.  He  had  no  convulsions  or  any 
spasmodic  movement,  and  was  conscious  till  within  a  few  hours  of  death  ; 
the  mother  states  that  there  was  unequivocal  evidence  of  his  recognition 
of  her  on  the  last  day  of  his  life.  He  died  April  17th,  nearly  three  weeks 
after  the  commencement  of  the  disease,  and  ten  days  after  the  commence- 
ment of  svmptoms  which  were  clearly  referable  to  the  brain. 

AuTOPfA'. — Abdominal  organs  healthy,  though  epigastric  pain  had  been 
so  constant  and  prominent  a  symptom ;  brain  a:nd  its  membranes  some- 
what injected.  The  meninges  covering  the  base  of  the  brain  from  the 
most  prominent  part  of  the  pons  Varolii  to  the  first  pair  of  nerves  pre- 
sented evidences  of  inflammation.  There  was  such  o])acity  of  the  pia 
mater  in  places  as  to  conceal  the  brain  from  view.  The  anterior  and 
middle  lobes  of  each  hemisphere  were  glued  together  by  fibrinous  exu- 
dation, and  on  the  left  side,  along  the  fissure  of  Sylvius,  was  a  thick 
deposit  of  the  same  character.  The  lateral  ventricles  contained  about  an 
ounce  of  clear  serum,  and  about  half  an  ounce  escaped  from  the  base  of 
the  brain.  The  foramen  of  ^lonro  was  considerably  enlarged,  and  the 
brain-substance  surrounding  the  lateral  ventricles  was  softened. 

In  this  case  it  is  seen  that  the  prominent  symptom,  and,  indeed, 
almost  the  only  marked  symptom  in  the  first  stages  of  the  disease,  was 
pain  in  the  abdomen,  and  yet  the  abdominal  organs  Averc  healthy.  At 
the  very  moment  when  it  was  highly  important  that  a  correct  diagnosis 
should  be  made,  the  evidences  of  cerebral  disease  were  lacking.  This 
case  is,  therefore,  interesting  on  account  of  the  variation  in  symptoms 
from  those  in  the  usual  form  of  meningitis.  There  Avere  no  convulsions, 
and  consciousness  avis  retained  as  well  sis  vision  till  near  the  close  of 
life,  and  yet  the  lesions  were  such  as  are  commonly  present  in  menin- 
geal inflammation.  It  is  in  such  cases  that  a  Avrong  diagnosis  is  fre- 
quently made,  to  the  injury  of  the  patient  and  the  reputation  of  the 
physician. 

Occasionally  meningitis  may  continue  .so  long  as  almost  to  justify  its 
being  called  chronic,  even  Avlien  there  is  a  large  amount  of  exudation 

30 


466  MENINGITIS. 

upon  the  pia  mater.  In  the  few  cases  which  end  favorably,  the  symp- 
toms abate  gradually.  I  shall  describe  more  fully  the  termination  in 
speaking  of  prognosis. 

Diagnosis. — ft  is  of  the  utmost  importance  to  diagnosticate  menin- 
gitis in  its  first  stages,  since  treatment,  to  be  successful,  must  be  com- 
menced early.  Certain  writers  describe  at  length  the  means  of  diag- 
nosticating the  simple  from  the  tubercular  form  of  the  inflammation. 
Differential  diagnosis  is  often  difficult,  and  sometimes  impossible ;  but 
it  matters  little,  practically,  whether  the  form  of  the  disease  be  ascer- 
tained. On  the  other  hand,  it  is  very  important,  in  order  that  the 
treatment  be  appropriate,  to  diagnosticate  tlie  premonitory  or  initial 
stage  of  meningitis  from  certain  other  affections  not  located  within  the 
cranium.  Sometimes  remittent  or  continued  fever,  or  constitutional 
disturbances  arising  from  irritation  in  the  digestive  system,  simulate 
closely  incipient  meningeal  disease,  so  that  the  greatest  care  and  dis- 
crimination are  required  in  order  to  make  a  correct  diagnosis.  Within 
a  comparatively  recent  period  I  have  known,  in  three  different  instances, 
experienced  physicians  of  this  city  mistake  commencing  meningitis  for 
fevers,  not  aware  of  the  serious  error  they  had  made  till  the  inflamma- 
tion had  reached  a  stage  from  which  recovery  was  impossible.  In 
order  to  avoid  error  in  the  diagnosis  in  the  premonitory  or  initial  stage 
of  meningitis,  the  physician  should  take  time  to  observe  the  physiog- 
nomy, and  note  every  symptom.  More  than  one  protracted  visit  is 
often  required  to  remove  doubt  as  to  the  exact  pathological  state. 

Meningitis  is  usually  preceded  and  in  its  commencement  accompa- 
nied by  greater  restlessness,  fretfulness,  intolerance  of  light,  and  a 
greater  variation  of  symptoms  than  most  other  maladies.  One  familiar 
with  the  physiognomy  of  infancy  and  childhood,  Avill  discover  in  the 
features  indication  of  greater  suffering,  of  more  serious  sickness,  than  is 
commonly  present  in  other  maladies  which  simulate  this. 

Sometimes  the  sudden  disappearance  of  a  chronic  eruption  upon  the 
scalp  will  aid  in  the  diagnosis.  This  is  a  sign  of  importance,  taken  in 
connection  with  the  symptoms.  Headache  and  vomiting,  symptoms  of 
early  occurrence,  sliould  especially  arrest  attention,  or,  in  absence  of 
headache,  pain  of  a  neuralgic  character  in  some  other  part.  But  we 
may  repeat  that  familiarity  with  the  symptoms  of  meningitis  will  not 
protect  from  error  if  the  visits  of  the  physician  are  hasty,  and  his  exami- 
nations imperfect.  When  the  eyes  become  affected,  the  respiration  and 
circulation  irregular,  and  especially  when  convulsive  attacks  begin, 
diagnosis  is  easy.  In  fact,  an  incorrect  diagnosis  would  then  be  unpar- 
donable; but,  unfortunately,  if  proper  treatment  have  not  been  com- 
menced till  this  period,  it  will  be  of  little  service. 

Prognosis. — Meningitis  is  one  of  the  most  fatal  maladies  of  early 
life.  Whether  the  form  be  tubercular  or  not,  if  the  initial  stage  have 
passed  Avithout  proper  treatment,  death  may  be  considered  inevitable. 
Tubercular  meningitis,  hoAvever  early  recognized,  is  rarely  amenable  to 
treatment.  M.  Guersant^  believes  tliat  recovery  from  the  first  stage 
of  this  form  of  meningitis  is  possible.  "  In  the  second  stage,"  says 
he,  "  I  have  not  seen  one  child  recover  out  of  a  hundred,  and  even 

^  Diet.  Med.,  t.  xix.  p.  403.  . 


PROGXOsis.  467 

those  who  seemed  to  have  recovered  have  either  sunk  afterward  under 
a  return  of  the  same  disease  in  its  acute  form,  or  have  died  of  phthisis. 
As  to  patients  in  whom  the  disease  has  reached  its  third  stage,  I  have 
nev'er  seen  ihem  improve  even  for  a  moment."  The  very  few  reported 
cases  which  resulted  favorably  may  have  been,  as  M.  Guersant  has  inti- 
mate^l  in  the  context,  cases  of  the  non-tubercular  form.  Rilliet  and 
Barthez  believe  that  in  a  few  instances  tubercular  meningitis  has  been 
cured  in  its  first  stage,  but  they  state  also  that  it  is  apt  to  return. 

The  prognosis  in  non-tubercular  meningitis  is  not  so  unfavorable,  pro- 
vided that  treatment  be  commenced  at  a  sufficiently  early  period.  It  is 
now  generally  admitted  that  it  may  not  infrequently  be  averted,  when 
threatening,  and  even  arrested  in  its  incipiency.  In  many  such  cases 
we  cannot,  from  the  nature  of  the  disease,  be  certain  that  the  diagnosis 
is  correct.  But  when  we  see  children  relieved,  who  present  precisely 
those  premonitory  and  even  initial  symptoms  which  occur  in  meningitis, 
we  must  believe  that  at  least  some  of  them  would  have  had  the  genuine 
disease  if  not  relieved  by  the  measures  employed.  That  in  its  com- 
mencement, recovery  is  possible  from  non-tubercular  meningitis  is  also 
obvious  from  the  fact  that  a  few  recover  even  in  the  second  stage,  when 
there  can  be  no  error  of  diagnosis. 

Although  a  considerable' proportion  of  patients  Avith  epidemic  cerebro- 
spinal meningitis  recover,  even  when  the  symptoms  have  been  most 
grave,  I  have  known  only  two  recoveries  from  sporadic  meningitis  when 
it  had  reached  that  stage  in  which  the  functions  of  the  brain  and  cranial 
nerves  were  impaired.  One  of  these  recovered  with  permanent  loss  of 
sight,  the  other  with  loss  of  hearing.  Both  seem  to  have  ordinary  in- 
tellinrence.  Another  case  has  been  communicated  to  me,  in  which  the 
patient,  a  little  child,  recovered  completely,  but  for  several  months  after 
the  attack  seemed  nearly  idiotic. 

Sometimes  even  in  the  second  stage  of  meningitis,  treatment  properly 
employed  is  attended  by  amelioration  of  symptoms.  Though  such  im- 
])rovement  may  serve  to  encourage  physician  and  friends,  it  should  not 
be  the  basis  for  a  f  ivorable  prognosis  unless  it  continue  three  or  four  days. 

Apparent  im|)rovemcnt  during  a  few  hours  or  a  considerable  part  of  a 
dav,  is  not  unusual  in  those  who  finally  die.  Thus,  in  an  infant  whose 
bowels  were  previously  confined,  I  have  known  the  pulse  and  respiration 
to  become  more  regular  and  the  symptoms  generally  improve,  though 
only  for  a  brief  period,  by  the  action  of  a  purgative.  Dr.  Watson  says 
of  the  advanced  stage  of  tliis  disease,  it  is  "often  attended  with  remis- 
sions, sometimes  sudden,  and  sometimes  gradual,  deceitful  ajipearances 
of  convalescence.  The  child  regains  the  use  of  its  senses,  recognizes 
those  about  him  again,  appears  to  his  anxious  parents  to  be  recovering, 
but  in  a  day  or  two  it  relapses  into  a  state  of  deeper  coma  than  before. 
And  these  fallacious  symptoms  of  improvement  may  occur  more  than 
once." 

Most  fatal  cases  of  meningitis  terminate  between  the  third  or  fourth 
an<l  the  twentieth  day,  the  duration  varying  according  to  the  extent  and 
intensity  of  the  inflammation,  and  the  vigor  and  age  of  the  patient.  But 
there  are  cases  in  which  it  may  continue  much  longer.  It  is  surprising 
sometimes  how  long  the  patient  lives,  when  the  symptoms  are  such  that 


■168  MENINGITIS. 

death  seems  impending.  Sensation  and  consciousness  may  be  extin- 
guished, convulsions  occur  at  intervals,  and  the  surface  have  acquired 
almost  a  cadaveric  aspect,  and  yet  the  patient  lives  on.  Rilliet  and 
Barthez  say  :  "  Often  have  we  inscribed  upon  our  notes  deatli  iinminent, 
and  been  astonished  the  next  day  to  find  still  alive  children  to  whom  Ave 
had  scarcely  allowed  two  hours  of  life."  The  symptom  which  I  have 
found  to  be  the  most  reliable  prognostic  of  the  near  approach  of  deatli, 
has  been  a  pulse  gradually  becoming  more  fre(iLient  and  leeble,  though 
other  symptoms  remain  as  before.  This  change  in  the  pulse  is  usually 
very  apparent  during  the  last  twenty-four  hours  of  life. 

Treatment. — Such  remedial  measures  should  be  prescribed  during 
the  premonitory  stage  as  are  calculated  to  relieve  the  fretfulness  or  irri- 
tability of  temper  and  quiet  the  action  of  the  brain,  and,  at  the  same 
time,  produce  a  derivative  effect  from  this  organ.  Q'o  this  end  the 
patient  should  be  kept  from  all  causes  of  excitement,  and  the  bowels 
should  be  opened  daily,  if  not  naturally,  by  the  use  of  proper  medicines. 
A  mustard  footbath  at  night  and  occasionally  through  the  day  is  useful, 
as  it  produces  both  a  derivative  and  soothing  eifect.  It  will  commonly 
pro<luce  a  few  hours'  undisturbed  rest,  while  all  other  measures  except 
medicines  fail.  If  dentition  be  taking  place,  and  the  gums  are  swollen, 
it  has  been  the  practice  to  employ  the  gum  lancet,  and  still  is  with  some 
physicians,  but  I  for  one  have  discarded  its  use  for  this  purpose.  Rest- 
lessness from  dentition  or  restlessness  premonitory  of  meningitis,  re- 
quires decided  doses  of  bromide  of  potassium,  which  will  relieve  the 
symptoms  more  eifectually  than  the  lancet.  Three  grains  should  be 
given  to  a  child  of  six  months,  and  four  grains  to  one  of  ten  or  twelve 
months,  and  repeated  if  necessary  in  two  to  four  hours.  If  symptoms 
indicate  the  near  approach  of  meningitis,  or  its  incipiency,  the  head 
should  be  kept  constantly  cool  by  a  cloth  wrung  out  of  ice-water,  or, 
better,  an  India-rubber  bag  containing  ice,  and  cantharidal  collodion 
should  perhaps  be  applied  behind  one  or  both  ears,  over  a  space  one 
inch  in  diameter. 

Many  children  Avho  are  threatened  Avith  meningitis  are  scrofulous. 
They  have  already  shown  symptoms  of  tubercular  disease.  They  are 
perhaps,  to  a  certain  extent,  emaciated,  and  may  have  been  affected 
Avith  a  cough.  The  premonitory  symptoms  in  these  children  indicate 
the  approach  of  the  tubercular  form  of  meningitis,  and  a  more  sustain- 
ing course  of  treatment  is  required  than  in  those  Avho  are  robust.  To 
such  children  cod-liver  oil  may  be  profitably  given,  three  times  daily, 
together  Avith  the  syrup  of  the  iodide  of  iron,  and  perhaps  the  bromide. 
They  should  also  be  taken  into  the  open  air,  Avith  proper  precautions, 
and  every  hygienic  measure  should  be  employed  Avhich  Avill  be  likely  to 
invigorate  the  system  Avithout  exciting  the  brain. 

Loss  of  blood  is  not,  in  general,  required  during  the  prodromic  jieriod 
nor  in  the  disease.  Those  of  a  strumous  cachexia,  or  those,  Avhether 
strumous  or  not,  Avho  are  under  the  age  of  tAvo  years,  do  not,  unless  in 
very  rare  instances,  require  depletion  by  leeches,  much  less  by  A'enesec- 
tion.  There  is  one  class  of  patients  in  Avhom  the  early  loss  of  blood 
mav  doubtless  be  of  service,  namely,  those,  Avho  in  a  state  of  robust 


T  E  E  A  T  M  E  N  T  .  4:69 

health  are  suddenly  seized  Avith  inflammation.  Leeches  may  then  be 
applied  to  the  head  of  the  patient,  if  he  be  seen  at  an  early  period. 

Often,  notwithstanding  the  measures  employed,  the  patient  grows 
worse,  the  symptoms  become  more  continuous,  others  more  ahirming 
arise,  and  meningitis  declares  itself.  Vriiatever  the  cause  of  the  inflam- 
mation, and  whatev^er  modifications  of  treatment  were  required  in  the 
premonitory  stage,  on  account  of  special  indications,  the  purpose  now  is 
to  subdue  the  inflammation  by  every  resource  in  our  art,  which  does  not 
injure  or  too  much  prostrate  the  system.  In  former  days  calomel  Avas 
largely  employed  as  the  main  remedy  in  this  disease,  but  when  adminis- 
tered daily  it  has  a  very  depressing  efiect,  and  it  is  to  be  borne  in  mind 
that  in  meningitis  the  vital  powers  progressively  fail  on  account  of  the 
loss  of  appetite,  vomiting,  etc.  In  tubercular  meningitis  depressing 
treatment  is,  of  course,  strongly  contraindicated,  cases  having  occurred 
in  wliich  calomel  was  given  at  short  intervals  for  several  successive  days, 
so  as  to  produce  a  laxative  effect,  and  though  the  meningitis  seemed  to 
be  controlled,  death  occurred  from  exhaustion,  or  from  some  intercurrent 
affection,  the  result  of  the  exhaustion.  Thus  in  one  case  related  to  the 
class  by  a  distinguished  professor  in  New  York  City,  fatal  gangrene  of 
the  mouth  supervened  from  the  mercurial  treatment,  after  the  meningeal 
inflammation  had  apparently  subsided.  Although  calomel  during  these 
last  years,  has  been  properly  discarded  as  the  main  remedy,  and  its  daily 
use  rejected,  nevertheless  it  is  very  useful  as  an  occasional  laxative  in 
the  more  robust  cases,  if  not  given  too  near  the  iodide  of  potassium, 
and  it  is  especially  indicated  as  a  derivative  from  the  head  in  children 
of  four  or  five  years,  who,  previousl}^  hearty  and  strong,  have  become 
suddenly  aff"ected  with  meningitis,  as  from  exposure  to  the  sun's  rays,  or 
from  an  injury.  But  I  repeat  the  belief  that,  in  ordinary  cases,  calomel 
should  never  be  employed,  except  as  an  occasional  laxative. 

The  two  remedies  upon  which  Ave  must  chiefly  rely  are  the  iodide  of 
potassium  and  the  bromide  of  potassium  or  sodium.  While  the  bromide 
quiets  the  restlessness,  prevents  convulsions,  and  diminishes,  there  is 
reason  to  think,  to  a  certain  extent,  the  hyperemia,  the  iodide  is  useful 
as  a  sorbefacient,  and  it  probably  has  some  control  over  the  inflamma- 
tion.    The  iodide  or  bromide  can  be  given  together  or  separately. 

The  iodide  should,  like  the  bromide,  be  given  early.  If  by  a  careful 
examination  the  absence  of  any  other  local  disease,  or  constitutional 
disease,  Avhich  might  give  rise  to  the  symptoms  be  ascertained,  and  the 
symptoms  indicate  the  meningeal  disease,  the  iodide  should  be  immedi- 
ately prescribed.  Obscurity  often  hangs  over  meningitis  at  this  early 
stage,  but  it  is  better  to  give  the  iodide,  even  if  the  diagnosis  be  Avrong, 
and  no  inflammation  have  commenced,  than  to  err  on  the  other  side, 
and  withhold  it  in  the  initial  jjcriod  of  the  true  disease,  for  it  is  not  an 
injurious  remedy  like  calomel,  and  to  exert  any  marked  curative  effect 
it  should  be  given  in  the  commencement  of  the  inflammation.  An  in- 
fant of  the  age  of  six  to  twelve  months  should  take  tAVO  grains  every 
two  hours,  and  older  children  a  proportionate  dose.  At  the  same  time 
the  bromide  should  be  giA'en  in  doses  tAvice  as  large  as  that  of  the  iodide, 
if  the  indications  for  its  use  are  present,  namely,  headache,  restlessness, 
ami  symptoms  Avhich  threaten  eclampsia.      The  bromide  is  a  harmless 


470  SPURIOUS    HYDROCEPHALUS. 

remedy  given  frequently  for  a  limited  time.  AVith  the  regular  and  con- 
tinued use  of  the  iodide  and  occasional  doses  of  bromide,  the  quantity 
of  urine  is  in  most  cases  largely  increased.  If  the  patient's  condition 
do  not  soon  begin  to  improve  with  such  treatment  there  is  no  remedy. 

If  convulsions  occur  the  bromide  should  be  given  every  ten  or  fifteen 
minutes  till  they  cease.  If  they  be  not  controlled  l)y  the  bromide,  an 
injection,  pt'r  rectutn,  of  three  to  five  grains  of  hydrate  of  chloral  in  a 
teaspoonful  of  water  should  be  used  in  addition.  Compresses  Avrung 
out  of  cold  water  frequently  applied  to  the  head,  or  a  bladder  containin<y 
joounded  ice,  and  separated  by  one  thickness  of  muslin  from  the  head, 
materially  aid  in  reducing  the  meningeal  hypen^mia.  Ergot,  recom- 
mended by  Brown-Se(|uard  for  its  supposed  effect  in  dmiinishing  the 
hyperemia  in  the  inflammatory  diseases  of  the  nervous  centres,  should 
also  be  employed  as  an  adjuvant  in  the  treatment  of  this  disease. 

In  the  first  stage  of  simple  meningitis  the  diet  should  be  mild  and  in 
moderate  quantity,  but  in  the  tubercular  form  it  should  from  the  first 
be  of  the  most  nourishing  kind,  consisting  of  beef-tea,  milk-porridge, 
etc.  At  a  more  advanced  stage  in  both  forms  of  the  malady  the  most 
nutritious  diet  should  be  allowed,  but  alcoholic  stimulants  should  not  be 
given  unless  near  the  close  of  life  when  the  vital  powers  are  failing. 
The  apartment  should  be  cool  and  quiet. 


CHAPTER    X. 

SPURIOUS  HYDROCEPHALUS 

The  disease  known  as  spurious  hydrocephalus  might  with  more  pro- 
priety be  called  spurious  meningitis.  It  received  its  appellation  at  the 
time  when  meningitis  of  early  life  Avas  believed  to  be  essentially  a  hydro- 
cephalus, and  was  so  called.  Attention  was  first  directed  to  this  malady 
by  London  physicians  of  the  last  generation,  particularly  by  Drs. 
Gooch,  Abercrombie,  and  Marshall  Hall,  and  little  can  be  added  to 
their  description  of  its  symptoms. 

Anatomical  Characters. — This  disease,  though  resembling  menin- 
gitis,  in  certain  of  its  phenomena,  is  not  in  its  nature  inflammatory, 
nor  is  it  primary.  It  is  the  result  of  some  malady  often  chronic,  but 
occasionally  acute,  which  has  produced  exhaustion,  especially  of  the 
nervous  system.  When  it  commences,  there  is  usually  more  or  less 
emaciation,  and  the  symptoms  of  the  primary  disease  are  present.  To 
this  disease  the  lesions  pertain  which  are  found  in  other  organs  beside 
the  brain. 

The  state  of  the  brain  in  spurious  hydrocephalus  is  not  the  same  in 
all  cases.  In  some  there  is  no  appreciable  anatomical  alteration  in  this 
organ.     There  is  no  apparent  difference,  either  in  the  meninges  or  the 


SYMPTOMS.  471 

brain  itself,  from  the  condition  whicli  we  often  observe  in  those  who 
have  died  of  diseases  which  do  not  affect  the  cerebro-spinal  system.  In 
such  cases  the  pathological  state  is  simply  deficient  innervation,  or  if 
there  be  a  structural  change  in  the  minute  anatomy  of  the  brain, 
pathologists  have  not  yet  discovered  it. 

The  following  case,  Avhich  occurred  in  the  Child's  Hospital  of  this 
city,  is  an  example  of  this  form  of  spurious  hydrocephalus: 

Case. — -A  female  infont,  six  months  old,  died  on  the  24th  day  of  April, 
1862,  with  the  following  history :  It  was  wet-nursed,  fleshy,  and  appar- 
ently well,  till  six  days  before  death,  when  symptoms  of  ga^tro-iutestinal 
inflammation  were  suddenly  developed.  The  vomiting,  esi)ecially,  was 
severe,  continuing  forty-eight  hours.  When  it  ceased,  drowsiness  super- 
vened, and  continued  till  the  close  of  life.  The  face  during  the  four  days 
of  stupor  was  pallid  and  cool;  eyes  partly  open,  pupils  sluggish,  but  of 
ecjual  size ;  bowels  i-ather  torpid ;  anterior  fontanelle  depressed.  When 
aroused,  the  infant  noticed  objects  for  a  moment,  and  immediately  relapsed 
into  sleep  ;  pulse  accelerated  and  not  intermittent,  the  day  before  death 
numbering  one  hundred  and  fifty  ;  respiration  accelerated,  without  sigh- 
ing, numbering  on  the  same  day  thirty.  There  were  no  cimvulsions,  and 
death  occurred  quietly.  The  l)rain  weighed  twenty  and  a  half  ounces, 
and  its  appearance  was  perfectly  heathy,  both  as  regards  consistence  and 
vascularitv.  The  amount  of  cerebro-sjjinal  fluid  in  the  ventricles  and  at 
the  base  of  the  brain  was  not  notably  increased.  The  stomach,  small  and 
large  intestines,  were  vascular  in  streaks  and  patches. 

In  this  case  the  cerebral  symptoms  were  obviously  due  to  exhaustion 
occurring  at  an  early  period,  in  consequence  of  the  severity  of  the  gas- 
ti*o-intestinal  malady. 

In  a  majority  of  cases,  however,  of  spurious  hydrocephalus,  according 
to  my  observation,  there  is  an  anatomical  alteration  in  the  state  of  the 
brain  and  meninges.  This  consists  in  passive  congestion  of  the  veins, 
often  with  transudation  of  serum.  At  the  same  time  the  cranial  sinuses 
are  congested,  and  are  found  at  the  post-mortem  examination  to  contain 
larger  and  more  numerous  clots  than  are  present  in  those  who  die  of 
diseases  which  do  not  affect  the  encephalon.  Cases  might  be  cited  as 
examples.  The  cause  of  this  congestion  and  effusion  is,  in  great  measure, 
feebleness  of  tlie  circulation  due  to  the  general  exhaustion  of  the  patient. 
]>ut  there  is  another  cause.  In  protracted  diseases,  osjiecially  those  of 
a  diarrhfjcal  character,  there  is  more  or  less  wasting  of  the  brain  as  well 
as  of  other  parts.  This  naturally,  by  way  of  compensation,  gives  rise 
to  congestion  of  the  cerebral  and  meningeal  veins  and  capillaries  and  to 
transudation  of  serum. 

The  transudation  commonly  occurs  in  this  malady  over  the  superior 
surface  of  the  brain  and  in  the  subarachnoidal  space,  perhaps  also  more 
or  less  in  the  lateral  ventricles.  So  common  is  it  in  the  last  stage  of 
infantile  entero-colitis,  the  summer  epidemic  of  cities,  that  this  stage, 
wiiich  is  really  spurious  hydroce))halus,  has  been  called  the  stage  of 
effusion.  I  shall  relate  in  another  place  examples  which  show  the 
anatomical  cliaracters  of  this  intestinal  disease. 

Symptoms. — Spurious  hydrocephalus  most  frequently  results  from 
protracted  diarrlnual  complaints.      It  may,   however,  result  from  any 


472  SPURIOUS    HYDROCEPHALUS. 

disease  Avhich  is  attended  by  great  prostration.  As  it  ordinarily  occurs, 
the  patient  has  for  days  or  weeks  been  gradually  losing  flesh  and 
strength.  Finally,  drowsiness  supervenes,  or  before  the  drowsiness 
there  is  sometimes  a  period  of  irritability. 

Marshall  Hall  describes  two  stages  of  s])urious  hydrocephalus.  In  the 
first  he  says :  '■'•  The  infant  becomes  irritable,  restless,  and  feverish  ;  the 
face  flushed,  the  surfxee  hot,  and  the  pidse  fi-equent ;  there  is  an  undue 
sensitiveness  of  the  nerves  of  feeling,  and  the  little  patient  starts  on 
being  touched,  or  from  any  sudden  noise ;  there  are  sighing  and  moan- 
ing during  sleep,  and  screaming ;  the  bowels  are  flatulent  and  loose, 
and  the  evacuations  are  mucous  and  disordered."  The  second  stage  he 
describes  as  that  of  torpor.  The  first  stage  often,  however,  does  not 
present  those  prominent  symptoms  which  have  been  described  by  Dr. 
Hall,  and  this  stage  may  even  be  absent,  or  not  appreciable,  especially 
in  3'oung  infants. 

Whether  or  not  commencing  with  the  stage  of  irritability,  the  dis- 
ease, if  not  checked,  gradually  increases.  The  child  soon  becomes 
drowsy.  lie  nuiy  be  aroused  for  a  moment,  but,  unless  constantly  dis- 
turbed, immediately  relapses  into  sleep.  He  is  sometimes  fi'ctful  when 
aroused,  but  in  other  instances  is  quite  indifferent,  observing  Avithout 
apparent  interest  objects  employed  for  the  purpose  of  amusing  him. 
Often  there  are  indications  of  cerebral  pain  or  distress,  as  contraction  of 
the  eyebrows,  etc.,  but  many  of  those  affected  are  too  young  to  make 
known  their  sensations.  Convulsions  sometimes  occur  toward  the  close 
of  life,  but  they  are  not  so  common  in  this  disease  as  in  meningitis. 
When  they  do  occur,  they  are  generally  partial  and  often  slight.  The 
pulse  is  accelerated  in  most  j^atients  prior  to  and  in  the  commencement 
of  spurious  hydrocephalus.  As  the  disease  advances  it  becomes  irregu- 
lar and  intermittent,  and  toward  the  close  of  life  it  is  progi'essively  more 
frequent  and  feeble.  The  respiration  at  first  is  not  much  disturbed,  but 
at  length  it  becomes  irregular,  like  the  pulse.  It  is  feeble  and  accompa- 
nied by  sighs.  Occasionally  there  is  slight  cough.  The  eyelids  are 
partly  open,  the  pupils  no  longer  respond  to  light,  and  in  advanced 
cases  they  have  a  bleared  appearance.  The  diarrhoea,  which  in  most 
instances  precedes  and  causes  this  malady,  continues  till  the  stage  of 
stupor  arrives,  wdien  the  evacuations  become  less  frequent  or  cease  alto- 
gether. In  infants  the  stools  are  frequently  green,,  in  older  children 
brown  and  sometimes  slimy.  The  febrile  heat  of  surface  which  pre- 
ceded the  disease,  and  which  was  present  in  its  commencement,  disap- 
pears; the  fiice  and  hands  become  cool,  the  features  pallid,  and  the 
anterior  fontaiielle,  if  open,  is  depressed.  Death  finally  occurs  in  a 
state  of  coma,  or  if  the  disease  be  recognized  and  proper  remedial  meas- 
ures employed,  the  result  may  be  favorable,  even  when  the  symptoms 
are  such  that  if  meningeal  inflammation  were  the  malady  we  would 
consider  the  case  necessarily  fatal. 

The  following  case  is  an  example  of  spurious  meningitis  as  we  often 
meet  it  in  practice  : 

Case. — On  the  13th  day  of  March,  18o9,  I  was  asked  to  see  a  male 
child  twentv-two  months  old,  the  records  of  whose  case  are  as  follows: 
"  Wa.s  well  till  about  three  weeks  ago,  since  which  time   he  has  had 


SYMPTOMS.  473 

diarrhoea,  with  febrile  symptoms;  pulse  102,  respiration  52;^  has  a  slight 
cougli,  with  a  few  mucous  rales  ;  resonance  on  percussion  of  chest  good  ; 
is  somewhat  emaciated,  and  appears  languid  ;  tongue  moist  and  slightly 
furred.  Has  all  the  incisor  and  three  anterior  molar  teeth,  and  the  gum 
is  swollen  over  the  remaining  anterior  molar  and  two  canine  teeth." 

"  From  the  14th  to  the  18th  there  was  no  material  alteration  in  his 
symptoms,  with  the  exception  that  the  diarrhoea  was  partially  restrained 
by  Dover's  powder  in  one  and  a  half  grain  doses.  On  these  hve  days  the 
stools  numbered  daily  from  one  to  six.  The  pulse  Avas  uniformly  frequent, 
varying  from  124  to' 156,  and  the  respiration  on  two  days,  when  its  fre- 
quency was  ascertained,  numbered  56  and  46. 

"March  19th,  pulse  124;  has  become  drowsy  since  yesterday,  and  when 
aroused  is  fietful.  Omit  Dover's  poAvder.  Treatment,  cold  applications 
to  the  head,  mustard  pediluvia. 

"  Evening,  pulse  136  ;  eyes  constantly  closed  and  head  reclining;  sur- 
face generally  warm  ;  tongue  dry  and  furred  ;  he  vomited  at  iirst,  but  has 
not  in  three  or  four  days.  Apply  cantharidal  collodion  behintl  each  ear, 
and  continue  the  local  treatment. 

"  20th,  pulse  130 ;  is  constantly  sleeping,  and  when  aroused  is  very  fret- 
ful and  soon  relapses  into  sleep  ;  no  unnatural  heat  of  head,  and  no  dejec- 
tion since  yesterday.     Treatment,  a  dose  of  castor  oil,  nourishing  diet. 

"  21st,  drowsiness  as  before  ;  cheeks  sometimes  flushed,  sometimes  pallid ; 
pupils  sensitive  to  light ;  margins  of  eyelids  covered  with  secretion.  The 
bowels  have  been  opened  by  the  oil." 

On  the  22d  and  23d  there  was  no  material  change  in  the  symptoms. 
He  was  constantly  sleeping,  except  for  a  moment  when  shaken.  More 
active  stinndation  was  now  em|)loyed.  Brandy  was  prescribed,  to  be  given 
every  two  hours;  beef  tea  and  milk  porridge  frequently. 

On  the  following  day,  the  24th,  he  was  more  fretful,  and  less  drowsy. 
Brandy  and  l)eef  tea  were  continued. 

On  the  25th,  with  the  same  treatment,  there  was  still  further  improve- 
ment;  drowsiness  nearly  gone  and  less  fretfulness  than  yesterday;  rolls 
the  head  occasionally  and  does  not  appear  to  see  distinctly ;  has  a  slight 
cough;  stools  nearly  regular;  pulse  100;  respiration  natural;  surface 
warm,  and  no  unnatural  heat  of  head.  The  same  treatment  was  con- 
tinued, and  he  rapidly  and  fully  I'ecovered. 

This  case  is  interesting  on  account  of  the  long  duration  of  marked 
drowsiness,  which  continued  five  days,  and  yet  the  patient  recovered 
entii-cly  in  the  space  of  t\vo  or  three  days  under  the  use  of  brandy  and 
beef- tea. 

In  May,  18G0,  I  was  called  to  treat  a  very  similar  case.  A  child, 
twenty  months  old,  had  diarrhiKa  for  two  weeks,  the  stools  being  of  a 
dark-brown  color,  thin  and  offensive.  He  Avas  at  first  very  irritable. 
The  pulse  was  constantly  aljove  130,  and  the  respiration  Avas  corre- 
s[)()niliugly  increased.  The  stage  of  drowsiness  finally  supervened,  and 
for  two  days  ho  Avas  constantly  asleep  unless  aroused  by  being  shaken. 
During  the  somnolent  stage  the  })ulse  numbered  140,  respiration  80. 
The  face  and  extremities  were  cool,  and  he  finally  had  a  slight  convul- 
sion. By  stimulants  and  nutritious  diet  he  began  immediately  to 
improve,  and  Avas  soon  out  of  danger. 

In  the  following  case  the  result  Avas  unfavorable.  This  case  is  inter- 
esting on  account  of  the  anatomical  characters  of  the  disease  as  disclosed 


474  SPURIOUS    HYDROCEPHALUS. 

by  the  post-mortem  examination.  It  is  an  example  of  tliat  large  class 
of  cases  in  Avhich  spurious  hydroceplialus  is  associated  "with  congestion 
of  the  cerebral  vessels  and  serous  efiusion.  It  is  exceptional,  however, 
as  regards  the  long  duration  of  drowsiness.  Ordinarily,  protracted 
diiirrha'al  maladies  -which  end  in  passive  congestion  and  effusion  termi- 
nate latally  in  three  or  four  daA's  after  the  drowsy  period  arrives. 

Case. — "Dec.  13,  1861,  called  to-day  to  a  German  infant  eighteen 
mouths  old.  It  has  had  diarluea  four  Avecks  without  regular  and  proper 
medical  attendance  ;  stools  from  the  first  brown  and  thin  ;  during  the  last 
eight  or  nine  days  he  has  been  drowsy;  when  aroused,  opens  his  eyes  and 
is  very  fretful,  but  immediately  the  u])per  eyelids  gradually  droop,  and, 
unless  disturbed,  he  reuuuns  asleej)  witli  his  eyes  i)artially  open  ;  forehead 
warm,  face  cool  and  pallid,  and  limbs  also  rather  cool  ;  pulse  104,  respira- 
tion 32 ;  has  had  a  slight  cough  about  one  week,  and  slight  dulness  on 
percussion  over  the  left  infra-scapular  region  ;  depression  of  infra-mam- 
mary i-egion  on  inspiration.  Treatment :  Amnion,  carbonat.,  gr.  1  every 
two  hours ;  nourishing  diet. 

"  Dee.  20th,  has  continued  drowsy  since  tliQ  last  record ;  })upils  mod- 
erately dilated  ;  a  thick  secretion  between  eyelids  ;  right  pupil  considerably 
larger  than  the  left;  vision  apparently  lost  during  the  last  three  days; 
pulse  over  140  ;  respiration  44  per  minute,  accompanied  by  sighing  since 
the  18th;  moans  much  Avhen  awake;  rolls  the  head  frequently;  during 
the  last  six  days  the  surface  back  of  the  ears  has  been  constantly  sore  by 
vesication;  takes  the  most  nutritious  diet,  with  brandy.  The  dejections 
remain  thin  and  brown,  and  number  three  or  four  daily. 

"  From  this  date  the  diarrhoea  continued,  except  as  it  was  restrained  by 
vegetable  astringents.  The  pulse  continued  frequent,  and  a  slight  cough 
remained.  There  was  on  the  21st  and  22d  partial  abatement  of  the 
drowsiness,  but  on  the  2od  it  was  greater  than  ever.  The  body  Avas  some- 
Avhat  I'educed  at  the  commencement  of  the  cerebral  symptoms,  but  it  Avas 
noAV  considerably  emaciated.  The  prostration  increased  dail}',  and  the 
hands  Avere  observed  to  trend^le.  The  face  and  hands  became  more  cool, 
Avhile  the  head  Avas  Avarm.  On  the  2-ith  partial  convulsions  occurred, 
followed  by  coma  and  death. 

"  The  cerebral  veins  and  sinuses  Avere  generally  congested,  except  in 
the  anterior  portion  of  the  brain,  A\here  the  appearance  was  normal.  Be- 
tween the  brain  and  its  membranous  covering,  chiefly  at  the  vertex  and 
the  base,  Avas  an  effusion  of  clear  serum.  The  Avhole  amount  of  this  fluid 
Avas  estimated  at  two  ounces.  On  slicing  the  brain,  numerous  *  puncta 
A'tusculosa '  were  seen,  both  in  the  gray  and  Avhite  ])ortions.  With  the  ex- 
ception of  the  congestion,  the  substance  of  the  brain  presented  its  normal 
appearance.  No  inflamnuitory  lesions  Avere  present.  We  Avere  not  per- 
mitted to  examine  the  condition  of  the  intestines." 

Diagnosis. — The  only  disease  Avith  Avhich  spurious  hydrocephalus  is 
liable  to  be  confounded  is  meningitis.  The  points  of  differential  diag- 
nosis are  the  history  of  the  case,  especially  the  antecedent  diarrhaa  or 
other  exhausting  ailment,  evidence  of  prostration  Avhen  the  cerebral 
malady  commenced,  depression  of  the  anterior  fontanelle  if  it  be  open, 
and  the  cool  face  and  extremities. 

PrognOi^IS. — If  the  pathological  state  of  the  brain  be  simple  exhaus- 
tion, the  disease  can  often  be  arrested  by  judicious  treatment.     If  an 


TREATMENT,  475 

incorrect  diagnosis  be  made,  and  the  treatment  employed  be  that  appro- 
priate for  meningitis,  which  it  so  closely  simulates,  death  is  almost 
inevitable.  If  transudation  of  serum  have  occurred,  unless  slight,  the 
result  is  usually  unfavorable,  whatever  may  be  the  treatment.  This 
disease  in  childhood  is  more  easily  managed  than  in  infancy,  but  is  less 
frequent.  The  prognosis  is  better  in  the  cool  months  than  during  the 
heat  of  summer.  It  is  more  favorable  if  the  child  be  over  than  if  under 
the  a^e  of  one  year.  The  occurrence  of  an  irregular  and  intermittent 
pulse,  of  respiration  accompanied  by  sighs,  of  inequality  in  the  pupils, 
or  their  sluggish  movements,  with  increasing  stupor,  indicates  an  unfa- 
vorable issue.  The  cure  of  the  primary  disease,  with  the  pulse  and 
respiration  still  natural,  or  accelerated,  without  change  of  rhythm, 
pupils  sensitive  to  light,  drowsiness  from  which  the  patient  is  easily 
aroused  to  a  state  of  entire  consciousness,  render  recovery  probable, 
with  proper  medication  and  alimentation. 

Treatment. — The  indications  of  treatment  are  twofold :  first,  to 
remove  the  primary  pathological  state  which  is  the  cause  of  the  spu- 
rious hydrocephalus ;  and,  secondly,  to  cure  the  latter.  The  first  is 
important,  since  the  successful  treatment  of  a  disease  requires  the 
removal  of  the  cause.  The  measures  employed  for  this  purpose  are 
pointed  out  in  our  description  of  the  diarrhceal  and  other  maladies  Avhich 
produce  spurious  hydrocephalus. 

AVe  may  here  say  that  as  spurious  hydrocephalus  is  due  in  a  very 
large  proportion  of  cases  to  the  exhausting  effect  of  long-continued  diar- 
rhoea, astringents,  especially  subnitrate  of  bismuth,  and  alkalies  ai'e 
required  in  a  majority  of  cases  in  the  stage  of  irritability,  and  sometimes 
also  opiates. 

Active  sustaining  measures  are  indicated.  Exhausted  nervous  power, 
as  well  as  passive  cerebral  congestion,  requires  this.  The  diet  should 
be  highly  nutritious,  comprising  such  substances  as  milk  and  beef-juice, 
and  should  be  given  frequently.  Brandy  is  required  at  short  intervals. 
Dr.  Gooch  was  in  the  hal)it  of  giving  the  aromatic  spirits  of  ammonia, 
properly  diluted,  as  a  quick  and  active  stimulant.  Six  or  eight  drops 
may  be  given  in  sweetened  water  to  a  child  one  year  old,  and  repeated 
every  hour  in  cases  of  urgency.  If,  by  proper  treatment  of  the  cause, 
and  by  the  use  of  stimulants  and  nutritious  food,  the  patients  do  not 
within  a  few  hours  become  less  stupid  and  more  conscious,  there  is  that 
degree  of  nervous  exhaustion  or  of  serous  transudation  from  the  engorged 
cerebral  veins,  which  will  render  death  probable.  In  some  cases  it  i3 
proper  to  produce  moderate  vesication  behind  the  ears. 


476  ECLAMPSIA. 


CHAPTER   XI. 

ECLAMPSIA. 

The  term  eclampsia  is  used  in  a  more  restricted  sense  by  some 
•writers  than  by  others.  It  is  employed  in  the  following  pages  to  desig- 
nate those  convulsive  seizures,  clonic  in  their  character,  sometimes 
general,  sometimes  partial,  which  affect  the  external  muscles.  Eclampsia 
is  therefore  synonymous  with  clonic  convulsions.  It  consists  in  rapid, 
forcible,  and  involuntary  muscular  contraction,  alternating  with  relaxa- 
tion. It  is  distinguished  from  chorea  in  the  fact  that  the  latter  is  a 
more  permanent  state,  and  is  characterized  by  muscular  movements 
which  are  partially  under  the  control  of  the  will,  and  are  not  so  violent. 

Eclampsia  occurs  in  a  great  variety  of  diseases,  some  of  which  are 
located  in  the  cercbro-spinal  system,  some  in  other  parts  of  the  body, 
and  some  are  constitutional.  It  may  also  be  produced  by  temporary 
derangements  of  system  not  sufficiently  severe  to  be  considered  dis- 
eases, and  by  powerful  mental  impressions,  those  of  an  emotional  nature, 
affecting  the  delicate  and  sensitive  nervous  system  of  the  child.  Pa- 
thologists recognize  three  different  forms  of  eclampsia.  The  term 
essential  or  idiopathic  is  used  when  the  convulsions  have  }io  ap)»reciable 
anatomical  character,  that  is,  when  there  is  no  apparent  patliological 
state  in  the  brain  or  elsewhere,  which  gives  rise  to  the  attack.  For 
example,  if  a  child  die  in  convulsions  from  fright,  and  all  the  organs, 
including  the  brain,  are  found  in  their  normal  state,  the  eclampsia  is 
called  idiopathic  or  essential.  If  the  cause  be  disease  of  the  brain  or 
spinal  cord,  it  is  termed  symptomatic.  If  eclampsia  arise  from  local 
disease  elsewhere  than  in  the  cerebro-spinal  axis,  as  from  pneumonia, 
the  term  sympathetic  is  employed.  This  is  in  the  main  a  good  division, 
but  eclampsia  may  be  at  the  same  time  sympathetic  and  symptomatic, 
as  when  it  occurs  in  consequence  of  congestion  of  brain,  which  is  induced 
by  severe  and  frequent  paroxysms  of  hooping-cough. 

Causes. — Eclampsia  occurs  at  any  period  of  infancy  and  childhood, 
but  it  is  much  more  rare  after  the  period  of  six  or  seven  years  than 
previously.  Some  children  are  more  liable  to  it  than  others.  It  is 
produced  in  one  by  an  agency  which  in  another  has  no  appreciable 
effect.  There  are  some,  generally  those  of  an  impressible  nervous 
system,  who  are  seized  with  convulsions  Avhenever  there  is  any  slight 
derangement  in  the  digestive  or  other  organs.  Eclampsia  is  frequent 
in  certain  families.  Thus,  Bouchut  menti(ms  a  family  of  ten  persons, 
all  of  whom  had  convulsions  in  their  infancy.  One  of  them  married, 
and  liad  ten  children,  all  which,  with  one  exception,  had  convulsions. 

The  exciting  causes  of  eclampsia  are  too  numerous  to  be  mentioned 
in  full.  It  is  a  symptom  in  nearly  all  cerebral  diseases.  It  is  produced 
in  the  nursling   by  changes  in  "the  milk  with  Avhich  it  is  nourished. 


PREMONITORY    STAGE.  477 

These  changes  are  usually  due  to  violent  emotions  of  the  mother,  as 
anther,  fright,  and  grief,  to  the  use  of  acescent  or  indigestible  food,  or 
to  derangement,  temporary  or  permanent,  in  her  health.  Thus,  in  a 
case  related  to  me,  the  catamenia  so  aifected  the  milk  that  the  infant 
•was  seized  with  eclampsia  at  each  monthly  period.  In  childhood  the 
most  common  cause  of  clonic  convulsions  is  the  presence  of  some  irri- 
tant in  the  prim?e  vi».  All  kinds  of  fruit,  even  the  mildest,  may  pro- 
duce eclampsia,  especially  Avhen  eaten  unripe  or  taken  in  undue  quan- 
titv.  I  have  known  an  infant  to  be  seized  with  convulsions  from  eating 
strawberries,  which  parents  usually  regard  as  harmless,  and  one  of  the 
most  violent  and  protracted  cases  of  eclampsia  which  I  have  witnessed, 
occurred  in  a  child  over  tlie  age  of  six  years,  from  swallowing,  in  con- 
siderable quantity,  the  parenchymatous  portion  of  an  orange.  Consti- 
pation, worms,  dysentery,  intussusception,  and  painful  dentition  are  also 
causes  wliich  are  located  in  the  digestive  apparatus.  Inflammation  in 
some  part  of  the  respiratory  apparatus  is  a  not  infrequent  cause. 
Tlius  eclampsia  occurs  occasionally  in  severe  coryza,  in  consequence, 
according  to  some,  of  the  proximity  of  the  inflamed  surface  to  the  brain, 
and  the  consequent  afflux  of  blood  to  this  organ.  It  is  a  common  com- 
plication also  of  pertussis  and  pneumonia.  It  occurs  often  at  the  com- 
mencement of  two  of  the  eruptive  fevers,  namely,  smallpox  and  scarlet 
fever,  and  in  the  course  of  the  latter  disease. 

Violent  emotions  of  the  child  may  also  cause  eclampsia.  Boiichut 
relates  the  case  of  a  girl,  five  years  old,  who  was  corrected  before  her 
companions,  and  was  so  affected  by  anger  that  convulsions  ensued. 
Kesidence  in  close  and  overheated  apartments,  or  in  streets  Avhere  the 
air  is  loaded  with  offensive  vapors  and  is  stifling,  is  a  predisposing 
cause,  so  that  there  is  a  larger  proportion  of  deaths  from  convulsions  in 
the  cities  than  in  the  country. 

In  young  children,  burns,  even  when  not  very  severe,  arc  liable  to  ter- 
minate suddenly  in  eclampsia,  succeeded  by  coma  and  death.  Urinary 
calculi,  both  renal  and  vesical,  frequently  produce  the  same  result. 

Such  are  the  more  common  causes  of  eclampsia.  It  is  seen  that 
they  are  of  two  kinds,  predisposing  and  exciting.  An  excitable  or 
inqtressible  state  of  the  nervous  system  constitutes  the  chief  predispo- 
sition to  the  disease.  Plethora,  or  its  opposite  state,  ansemia,  increases 
the  liability  to  an  attack. 

Premonitory  Stage. — In  the  majority  of  cases  there  are  prodromic 
symptoms,  which  the  experienced  and  careful  physician  can  detect,  so 
as  to  forewarn  friends.  The  chihl  is  perhaps  more  or  less  droAvsy,  and, 
when  disturbed,  fretful.  The  eyes  often  have  a  wihl  or  unnatural 
appearance;  occasionally  they  are  fixed  for  a  moment  on  an  object,  and 
yet  apparently  without  noticing  it.  The  sleep  is  disturbed;  in  some 
there  is  unusual  heat  of  head,  and,  if  old  enough,  complaint  of  head- 
ache. At  times,  e>pecially  if  the  primary  disease  be  febrile  or  inflam- 
matory, there  is  incoherence  of  thought  or  e.\i)ression,  or  even  actual 
delirium.  In  some  children,  when  eclanq)sia  is  threatening,  the  thumbs 
are  seen  to  be  carried  across  the  palms.  I  have  observed  this  especially 
during  the  convulsive  cough  of  pertussis.  A  very  important  prognostic 
symptom  is  sudden  starting,  or  twitching  of  the  limbs.     This  shows 


478  ECLAMPSIA. 

that  the  nervous  system  is  pi'ofoundly  impressed,  and  but  slight  addi- 
tional excitation  is  required  to  develop  eclampsia.  This  sudden  starting 
not  infrequently  precedes  the  attack  several  hours,  and  gives  sufficient 
forewarning. 

The  })ro(h-omic  symptoms  are  often  disregarded  by  friends  who  do  not 
understand  their  significance.  Even  physicians,  in  the  haste  of  their 
visits,  in  many  instances  do  not  notice  them.  The  symptoms  which 
precede  symptomatic  and  sympathetic  eclampsia,  are,  moreover,  blended 
with  those  of  the  primary  affection,  and  hence  another  reason  why  they  are 
fre(|uently  overlooked.  AVhen  the  convulsions  are  about  to  commence, 
the  child  generally  lies  quiet ;  the  eyes  are  open  and  fixed.  If  spoken 
to  or  shaken,  he  takes  no  notice,  and  does  not  speak.  The  direction  of 
the  eyes  is  then  changed ;  often  they  are  turned  up ;  occasionally  there  is 
strabismus.  The  face  may  be  pale  or  flushed,  and  sometimes,  especially 
in  cerebral  diseases,  the  features  present  patches  or  streaks  of  a  flushed 
appearance,  while  around  them  the  natural  color  is  preserved.  Imme- 
diately before  the  spasmodic  movements  the  child  sometimes  utters  a 
piercing  scream,  which  is  probably  involuntary,  though  it  seems  like  a 
supplication  for  help.  The  duration  of  the  prodromic  stage  is  very  dif- 
ferent in  different  cases.  It  may  last  from  a  few  minutes  to  several 
hours,  or  even  more  than  a  day. 

Symptoms. — Eclampsia  is  general  or  partial.  \^ general.,  the  muscles 
of  the  face,  eyes,  eyelids,  and  of  all  the  limbs,  are  in  a  state  of  rapid  in- 
voluntary contraction,  alternating  with  relaxation.  The  features  lose 
their  natural  expression  and  arc  distorted ;  the  mouth  is  drawn  out  of 
shape,  often  to  one  side,  by  the  violent  muscular  action ;  the  teeth  are 
pressed  together  by  tonic  contraction  of  the  masseters,  and  may  be  vio- 
lently struck  together,  so  as  to  lacerate  the  tongue,  if  it  protrude,  or  are 
ground  upon  each  other.  Unless  the  attack  be  of  short  duration,  frothy 
saliva,  perhaps  tinged  with  blood  from  the  injured  tongue,  collects  be- 
tween the  lips.  The  eyelids  are  usually  open,  and  in  severe  cases  the 
eyes  are  turned  so  that  the  pupils  are  lost  under  the  upper  eyelids,  or 
the  muscles  of  the  eyes  are  involved  in  the  spasmodic  movements,  so 
that  the  eyeballs  are  forcibly  drawn  from  side  to  side.  Occasionally 
strabismus  occurs.  While  the  features  are  thus  distorted,  the  head  is 
strongly  retracted  or  is  turned  to  one  side  ;  the  forearms  are  alternately 
pronated  and  supinated  ;  the  thumbs  and  fingers  are  convulsively  flexed, 
so  that  the  thumbs  lie  across  the  palms  and  are  covered  by  the  fingers ; 
the  great  toe  is  adducted,  the  other  toes  flexed ;  and  the  toes,  as  well  as 
legs,  participate  more  or  less  in  the  spasmodic  movements. 

In  general  convulsions,  consciousness  is  usually  lost.  The  head  is 
hot  previously  to  and  during  the  attack — at  least  in  the  first  part  of  it — 
and  the  face  flushed.  In  exceptional  cases,  especially  in  sympathetic 
eclampsia,  the  head  is  cool  and  the  fiice  pallid.  The  pulse  is  somewhat 
accelerated,  as  well  as  the  respiration,  and  the  latter  is  rendered  irreg- 
ular if  the  respiratory  muscles,  especially  those  of  the  larynx,  are  in- 
volved, as  they  generally  are.  The  sphincters  are  relaxed  during  the 
convulsive  attack,  so  that  in  many  cases  the  urine  and  stools  are  passed 
involuntarily. 


PREMONITORY    STAGE.  479 

Partial  eclampsia  is  more  common  than  the  general  form ;  it  occurs 
in  the  muscles  of  the  face,  including  those  of  the  eye,  of  the  face  and  of 
one  or  both  upper  extremities,  or  of  the  face  and  the  extremities  on  one 
side.  The  spasmodic  movements  may  be  even  limited  to  the  muscles  of 
the  eye,  and  they  often  occur  only  in  these  muscles  and  those  of  the  fiice. 
Rarely,  if  ever,  does  eclampsia  affect  the  legs  Avithout  affecting  also  the 
muscles  of  the  arms  and  face.  In  partial  convulsive  attacks,  sensation 
and  consciousness  are  in  some  patients  not  entirely  lost,  but  in  others 
they  are  not  manifested  if  present. 

The  duration  of  an  attack  of  eclampsia  varies  in  different  cases  from  a 
few  minutes  to  several  hours,  with  an  average  of  not  more  than  from 
five  to  fifteen  minutes.  The  movements  do  not  often  continue  longer 
than  three  or  four  hours  in  the  severest  cases.  They  are  sometimes 
said  to  last  a  much  lon^ier  time,  even  for  davs,  but  in  these  cases  there 
are  intermissions.     Violent  attacks  are  usually  short. 

When  the  convulsion  ends  favorably,  the  spasmodic  movements  become 
less  and  less  strong,  and  finally  cease.  The  child  then  takes  a  deep  in- 
spiration, after  which  it  lies  quiet,  and  the  respiration  remains  regular 
or  moderately  accelerated.  Some  fally  recover  in  a  few  minutes  if  the 
eclampsia  have  been  light  and  the  cause  transient,  and  seem  to  experi- 
ence no  inconvenience  except  soreness  of  the  muscles  and  fatigue. 
Others  soon  recover  consciousness,  and  their  temperature,  respiration, 
and  circulation  become  natural,  but  they  remain  dull  for  a  time,  their 
minds  are  bewildered,  and  they  are  perhaps  unable  to  speak.  In  a  few 
hours  these  untoward  symptoms  pass  away.  In  essential,  and  in  a  large 
proportion  of  cases  of  sympathetic  eclampsia,  if  properly  treated,  and  if 
the  cause  be  recognized  and  removed,  there  is  no  recurrence  of  the  con- 
vulsion ;  with  others  it  is  different.  In  many  cases,  especially  of  symp- 
tomatic eclampsia  and  of  sympathetic,  in  which  the  cause  is  grave  and 
persistent,  the  convulsions  I'eturn  after  a  variable  period  of  a  few  minutes 
or  a  few  hours.  Six  or  eight  or  more  convulsions  may  occur  within 
twenty-four  hours.  Rarely  they  occur  several  times  daily  for  several 
consecutive  days,  but  severe  convulsions,  repeated  at  short  intervals  for 
twenty-four  or  forty-eight  hours,  usually  end  in  fatal  congestion  of  the 
brain  or  serous  effusion.  I  once  attended  an  infant  about  six  months 
old,  who  had  from  four  to  twelve  convulsions  daily  for  eleven  days, 
caused  probably  by  a  vesical  calculus,  as  there  was  dysuria,  and,  at 
times,  bloody  urine.  Some  days  after  the  convulsions  were  controlled, 
while  we  were  deferring  exploration  of  the  bladder,  death  occurred  sud- 
denly, and  an  autopsy  was  not  permitted.  This  case  will  be  detailed 
elsewhere.  Bouchut  has  witnessed  a  case  of  hooping-cough  in  which 
there  were  daily  convulsions  for  eighteen  days. 

In  severe  eclampsia,  the  respiration  is  so  embarrassed  and  circulation 
so  retarded  that  congestion  of  various  organs  results.  This  passive  con- 
gestion in  the  respiratory  organs  is  indicated  by  moist  niles  in  the  larynx 
and  bronchial  tubes;  occurring  in  the  brain,  it  is  indicated  by  profound 
stupor.  It  has  already  been  stated  that  death  may  occur  from  the 
cerebral  congestion,  which,  continuing,  is  apt  to  end  in  effusion  of 
serum  or  extravasation  of  blood.  In  these  cases  the  convulsive  move- 
ments cease,  but  there  is  no   return  of  consciousness.     The  child  lies 


480  ECLAMPSIA. 

quiet,  as  if  in  sleep,  with  pupils  not  readily  acted  on  by  light,  and  often 
somewhat  dilated  ;  gradually  the  liml)S  grow  cool  and  tlie  pulse  feeble, 
and  fatal  cnma  supervenes. 

Death  does  not  ordinarily  occur  from  one  attack.  There  are  several 
at  intervals,  during  which  the  stupor  is  gradually  becoming  more  and 
more  profound,  till,  finally,  total  loss  of  consciousness  and  sensation 
results,  terminating  in  death.  Apnoca  may  occur  in  the  first  attack, 
ending  life  abruptly  and  unexpectedly,  but  in  other  instances  it  does  not 
result  till  after  several  seizures,  when,  at  length,  one  more  violent  than 
the  others  interrupts  the  respiratory  function  and  causes  death. 

Occasionally,  Avhen  life  is  preserved,  there  is  some  permanent  ill-effect 
of  eclampsia.  Bouchutsays:  "  The  origin  of  certain  permanent  con- 
tractions which  bring  on  deviation  of  the  head  or  of  other  parts,  retrac- 
tion of  the  limb,  paralysis,  etc.,  must  be  referred  to  the  convulsions  of 
the  muscles.  I  have  seen  several  children  in  whom  torticollis  liad  no 
other  cause.  The  di'00})ing  of  the  upper  eyelid,  strabismus,  irregularity 
of  the  mouth,  severe  contractions  of  the  limbs,  often  depend  on  this 
iniluence.  These  accidents  are  consequences  of  essential  as  well  as  of 
symptomatic  convulsions." 

Anatomical  Characters. — The  morbid  anatomy  pertaining  to 
eclampsia  is  in  most  cases  twofold:  first,  the  pathological  states  Avliich 
precede  and  cause  the  convulsive  movements ;  secondly,  those  which 
result  from  them.  We  have  seen  that  in  sympathetic  eclampsia  the  dis- 
eases which  sustain  a  causative  relation  are  very  numerous;  some  are 
constitutional,  others  local,  and  the  latter  may  have  their  seat  in  almost 
any  part  of  the  economy,  distinct  from  the  cercbro-spinal  axis.  In 
some  cases  of  sympathetic  eclam})sia  the  immediate  cause  is  too  active  a 
circulation,  a  state  of  hypernemia  of  the  cerebral  vessels. 

It  has  already  been  stated  that  this  hypergemia  may  be  diagnosticated 
in  young  infants  in  whom  the  anterior  fontanelle  is  open.  Such  infants, 
seized  with  acute  inflammation  of  the  mucous  surfaces  or  of  the  lungs, 
often  present  a  full  and  rapid  pulse  and  a  convex  and  forcibly  pulsating 
fontanelle  before  the  eclampsia  begins.  In  other  cases  of  sym})athetjc 
eclampsia  the  primary  disease  induces  passive  congestion  of  the  brain, 
and  this  in  turn  gives  rise  to  convulsions.  Eclampsia  occurring  during 
the  paroxysms  of  hooping-cough  affords  an  example.  In  the  contagious 
diseases,  as  smallpox  and  scarlet  fever,  eclampsia  is  doubtless  often 
produced  by  the  direct  action  of  the  specific  virus  on  the  cerebro-spinal 
system.  Therefore,  in  a  considerable  proportion  of  cases  of  eclampsia 
due  to  diseases  not  located  in  the  cerebro-spinal  system — in  other 
words,  of  sympathetic  eclampsia — the  primary  disease  induces  a  patho- 
logical state  of  the  cerebral  vessels,  or  of  the  blood  which  circulates 
through  them,  which  state  immediately  precedes  and  accompanies  the 
convulsions. 

In  other  cases  of  sympathetic  eclampsia  the  convulsive  movements 
are  produced  by  the  primary  disease  acting  directly  on  the  nervous 
system,  tlirough  the  medium  of  the  nerves,  Avithout  causing  any  appre- 
ciabla  alteration  in  the  state  of  the  cerebro-spinal  axis.  Thus  Barrier 
relates  three  fatal  cases  of  convulsions  occurring  in  pneumonia,  in  none 


DIAGNOSIS.  481 

of  which  was  there  anything  abnormal  in  the  condition  of  the  brain  or 
its  menibranes. 

Tlie  pathological  state  preceding  symptomatic  eclampsia  differs  in 
different  cases,  since  convulsions  occur  in  almost  every  disease  of  the 
brain  and  its  membranes.  The  immediate  cause  of  this  form  of 
eclampsia  may  be  active  or  passive  cerebral  congestion,  with  or  Avith- 
out  eftusion ;  it  may  be  compression  of  the  brain  from  various  causes ; 
it  may  be  a  deficiency  as  well  as  excess  of  the  cerebro-spinal  fluid. 

In  essential  eclampsia  the  cause  sometimes  produces  congestion  of 
the  brain  prior  to  the  convulsive  seizure.  In  other  cases,  as  when  con- 
vulsions occur  immediately  from  the  effect  of  anger  or  fright,  there  is 
no  appreciable  change  in  the  state  of  the  nervous  centres  previously  to 
the  attack. 

Again,  eclampsia,  especially  when  severe  and  protracted,  and  when 
occurring  in  successive  attacks,  may  be  the  cause  of  certain  lesions. 
It  produces  congestion  of  the  brain  and  membranes,  and  perha})S  of 
the  spinal  cord.  Sometimes  if  the  congestion  be  great,  there  is  also 
escape  of  serum  from  the  distended  capillaries,  and  the  fibrin  in  the 
larger  vessels,  as  the  sinuses,  may  coagulate. 

Ths  congestion  resulting  from  eclampsia  may  give  rise  to  extravasa- 
tion of  blood  and  the  formation  of  a  clot.  If  this  accident  occur,  there 
is  often  paralysis  affecting  more  or  less  of  one  side,  permanently  or 
gradually  disa])pearing. 

It  may  be  difficult  to  decide  whether  the  cerebral  congestion  precedes 
the  eclampsia  or  is  its  result ;  but  in  those  cages  in  which  it  precedes 
and  operates  as  a  cause,  it  is  no  doubt  increased  during  the  convulsive 
period.  'Che  spasmodic  muscular  action,  by  rendering  respiration 
irregular  and  im])erfect,  also  leads  to  congestion  of  the  lungs  and  some- 
times of  the  abdominal  organs. 

Diagnosis. — The  only  disease  for  which  there  is  danger  of  mis- 
taking eclampsia  is  epilepsy,  but  the  diagnosis  can  ordinarily  be  made 
by  recollecting  the  following  facts  :  Eclampsia  is  most  common  in 
infancy.  If  it  occur  after  the  age  of  three  years  there  is  some  manifest 
exciting  cause,  which  renders  the  child  seriously  sick  independently  of 
the  Convulsions,  and  prior  also  to  their  occurrence.  Eclampsia  very 
seldom  occurs  in  one  wlio  has  reached  the  age  of  three  years,  even  with 
a  strong  predisposing  cause,  unless  he  have  been  subject  to  it  during 
the  period  of  infancy,  as  shown  by  his  history.  On  the  other  hand,  epi- 
lepsy rarely  occurs  bef  )re  the  age  of  three  years.  The  first  attacks  of 
it  are  very  often  mild,  the  petit  mal  of  writers,  but  in  other  cases  they 
are  tolerably  severe  from  the  first,  but  whether  mild  or  severe,  they 
occur  with  no  previous  or  coexisting  sickness,  and  with  little  or  no 
warniniT. 

Having  seen  a  considerable  num1)er  of  epileptic  children  in  the 
Bureau  for  the  Relief  of  the  Outdoor  Poor  during  the  last  ten  years.  I 
have  been  surprised  to  learn  how  few  had  eclampsia  when  infants.  It 
was  exceptionally  the  case  that  a  child  having  epileptic  attacks  com- 
mencing as  ordinarily  they  did,  between  the  thinl  and  tenth  years,  gave 
the  history  of  infantile  eclampsia,  and  yet  the  convulsive  movements  in 
the  two  diseases  seem  to  be  identical.     I  cannot  agree  with  some  that 

31 


482  ECLAMPSIA. 

the  phenomena  in  echmipsia  and  epilepsy  differ,  except  as  the  causes  of 
echxmpsia  produce  certain  concomitant  sym})toms,  and  there  is  every 
reason  to  believe  that  the  spasmodic  muscular  movements  proceed  from 
an  irritation  of  the  same  portion  of  the  cerebro-spinal  axis,  to  wit,  the 
medulla  oblongata.  Writers  like  Niemeyer  have  given  reasons  for  the 
])elief  that  spasmodic  muscular  movements  are  produced  by  functional 
disturbance  of  this  part  of  the  nei'vous  centre.  I  may  state  the  follow- 
ing, to  ■which  I  am  not  aware  that  any  one  has  alluded.  If  the  exposed 
medulla  of  an  acephalous  monster  be  pressed  or  pinched,  convulsions  like 
those  of  eclampsia  and  epilepsy  result.  These  two  diseases,  therefore, 
have  a  close  resemblance  anatomically  and  clinically,  but  by  attention  to 
the  above  facts  they  can  ordinarily  be  distinguished  from  each  other. 

It  is  often  difficult  to  ascertain  the  form  of  eclampsia,  whether  essen- 
tial, symptomatic,  or  sympathetic — in  other  words,  to  determine  the 
cause — till  after  the  convulsions  cease.  This  is  especially  true  when,  as 
is  frequently  the  case,  the  physician  is  not  summoned  till  the  convulsive 
movements  begin,  and  it  is  necessary  that  he  should  act  promptly,  with 
but  little  knowledge  of  the  child's  previous  history.  If  there  be  an 
obvious  antecedent  disease,  as  hooping-cough  or  meningitis,  the  cause  is 
apparent ;  but  if  the  previous  health  have  been  good,  or  but  slightly  dis- 
turbed, it  may  be  necessary  to  make  more  than  one  visit  or  examination 
in  order  to  ascertain  the  seat  and  character  of  the  cause.  In  the  ma- 
jority of  cases  of  convulsions  occurring  suddenly  in  a  state  of  previous 
good  healtli,  the  cause  is  seated  in  the  intestines,  but  sudden  and  unex- 
pected attacks  may  be  due  to  the  commencement  of  some  inflaumiatory 
affection,  as  pneumonia,  or  of  a  febrile  disease,  as  smallpox.  Unless  the 
eclampsia  be  speedily  fatal,  the  physician,  if  he  examine  carefully,  will, 
in  most  cases,  soon  be  able  to  ascertain  the  nature  of  the  cause,  and 
diagnosticate  the  form' of  the  disease. 

Prognosis. — Symptomatic  eclampsia  is  always  serious.  If  it  occur 
in  the  course  of  a  cereljral  disease,  it  indicates  the  approach  of  death, 
but  if  at  the  commencement,  some  may  recover.  Its  recurrence,  what- 
ever the  cerebral  disease,  is  an  almost  certain  prognostic  of  death. 

In  idiopathic  or  essential  convulsions  the  prognosis  depends  on  the 
severity  of  the  attack,  and  on  the  age,  strength,  and  previous  condition 
of  the  child.  If  tliere  be  predisposing  or  cooperating  causes,  as  a  nervous 
or  excitable  temperament,  or  dentition,  the  prognosis  is  less  favorable 
than  when  such  causes  are  absent. 

In  sympathetic  eclampsia  the  prognosis  varies  greatly,  according  to 
the  nature  of  the  primary  disease,  and  often  according  to  the  stage  of 
that  disease.  If  convulsions  occur  at  the  commencement  of  an  eruptive 
fever,  they  generally  subside  without  untoAvard  symptoms,  and  the  fever 
pursues  a  favorable  course.  Eclampsia,  after  the  appearance  of  the 
eruption,  is  premonitory  of  a  fatal  result.  I  have  not  yet  known  a 
patient  with  scarlet  fever  recover  who  had  convulsions  after  the  rash 
had  covered  the  body,  and  experienced  physicians  of  this  city  tell  me 
that  their  observations  correspond  with  mine.  Dr.  J.  F.  Meigs,  how- 
ever, relates  one  favorable  case.  If  the  cause  of  the  eclampsia  be 
located  in  or  upon  the  mucous  surfaces,  a  majority  recover  with  judi- 


TREATMENT.  483 

cious  treatment.  In  convulsions  consequent  on  pneumonia  or  a  burn, 
more  die  than  recover. 

The  prognosis  in  echimpsia  is  more  favorable  if  the  parallelism  of  the 
eyes  be  retained,  the  pupils  remain  sensitive  to  light,  and  consciousness 
soon  return.  A  fatal  termination  may  be  predicted,  if,  after  the  convul- 
sion, the  child  remain  stupid,  without  any  evidence  of  returning  con- 
sciousness, and  the  pupils  do  not  respond  to  light. 

Treatment. — Fortunately,  inasmuch  as  the  physician  is  often  re- 
quired to  treat  eclampsia  in  ignorance  of  the  cause,  the  same  measures 
arc  demanded,  to  a  considerable  extent,  in  all  cases,  -whether  the  form 
be  essential,  symptomatic,  or  sympathetic.  As  early  &s  possible  in  the 
attack  the  feet  should  be  placed  in  hot  water  to  which  mustard  is  added, 
or,  if  it  can  be  procured  Avith  little  delay,  a  general  warm  bath  may  be 
used  in  its  place.  This  has  a  soothing  effect  upon  the  nervous  system  and 
promotes  muscular  relaxation,  while  it  also  produces  derivation  of  blood 
from  the  cerebro-spinal  axis.  It  is,  therefore,  useful,  especially  in  those 
cases  in  which  active  or  passive  congestion  precedes  the  eclampsia ;  it  is 
also  useful  as  a  preventive  of  passive  congestion  and  consequent  oedema 
of  the  brain,  lungs,  and  other  organs,  which  are  the  most  serious  results 
of  eclampsia.  It  should  be  continued  from  six  to  fifteen  or  twenty 
minutes,  according  to  the  severity  and  duration  of  the  attack ;  at  the 
same  time  cold  applications  should  be  made  to  the  head,  until  its  tem- 
perature, which  is  usually  increased,  is  reduced.  The  application  of 
cloths  placed  upon  ice  or  frequently  wrung  out  of  cold  water,  is  the 
most  convenient  and  ready  mode  of  employing  this  agent.  Cold  thus 
employed  acts  promptly  in  contracting  the  vessels  of  the  brain  and 
meninges,  and  diminishing  the  cerebral  congestion.  It  tends,  therefore, 
to  remove  one  of  the  chief  dangers. 

Cold  applications  are  also  useful  for  reducing  an  elevated  temperature, 
if  it  be  present.  In  most  cases  of  eclampsia,  if  the  temperature  reach 
108°,  the  necessity  for  its  reduction  is  urgent,  and  the  cloths  or  India- 
rubber  bag  containing  ice  should  be  applied  not  only  upon  the  head, 
but  also  along  the  sides  of  the  face,  and  sometimes  over  the  great  vessels 
of  the  neck. 

As  a  large  proportion  of  convulsive  attacks  originate  in  the  condition 
of  the  intestines,  either  solely  or  in  part,  it  is  advisable  to  prescribe  an 
aperient  unless  tliere  be  previous  diarrluea. 

The  common  enema  of  soaj)  and  water  will  usually  produce  a  free  and 
speedy  evacuation,  and  will  sometimes  disclose  the  cause  of  the  eclampsia 
in  the  expulsion  of  seeds  or  other  indigestible  sul)stances  or  scybala.  A 
cathartic  is  also  often  required,  especially  if  the  enema  fail  to  produce 
sufficient  evacuations.  In  those  that  are  robust,  and  especially  in  those 
beyond  the  age  of  two  or  tliree  years,  calomel  is  an  excellent  ])urgative, 
is  ciusily  given,  and  is  prompt  in  its  action.  If  the  symptoms  indicate 
intestinal  inflammation,  the  mihler  purgatives,  as  castor  oil,  are  prefera- 
ble, as  they  also  are  in  young  or  feeble  children.  If  the  recent  ingesta 
of  the  patient  consisted  of  fruit  or  of  substances  of  an  indigestible  char- 
acter, an  emetic  is  appropriate;  a  teaspoon ful  of  the  syrup  of  ipocac- 
uanlia,  repeate<l  if  necessary  in  fifteen  or  twenty  minutes,  may  be  given 
to  a  young  child,  or  tliis  syrup  mixed  with  the  syrup,  scilke  couipositus 


484  ECLAMPSIA. 

to  one  older  and  more  robust.  Aside  from  the  ejection  of  the  offend- 
ing substance  which  it  produces,  an  emetic  has  some  effect  in  con- 
trolling the  convulsive  movements.  But  the  cases  are  rare  in  which 
emetics  are  indicated. 

In  addition  to  the  local  m  'asurcs  mentioned  above,  and  measures  cal- 
culated to  relieve  the  digestive  canal  of  any  offending  substance,  a  safe 
medicinal  agent  which  will  act  promptly  in  relieving  the  convulsions  is 
urgently  demanded,  since  eclampsia,  if  severe  and  protracted,  involves 
great  danger.  Fortunately  such  agents  have  been  lately  introduced  into 
therapeutics,  namely,  the  bromide  of  potassium  or  sodium,  and  hydrate 
of  chloral.  Tlie-e  agents,  while  they  are  effectual,  are  safe,  and,  there- 
fore, their  use  has  su})planted  tliat  of  the  antispasmodics,  asafoetida, 
valerian,  lavender,  and  cidoroforin,  formerly  employed;  not  one  of  which, 
except  chloroform,  exerts  any  direct  controlling  influence  over  the  con- 
vulsions, and  chloroform  is  a  dangerous  remedy  unless  used  sparingly. 

The  bromide  of  potassium,  which  I  ])refer,  should  be  given  every  ten 
minutes,  dissolved  in  c:)ld  water,  till  the  convulsicms  cease,  in  doses  of 
three  grains  to  a  child  of  one  year,  and  of  f  )ur  or  five  grains  to  a  child 
of  two  or  three  years.  When  the  convulsions  cease,  the  interval  between 
the  doses  should  be  lengthened.  In  one  instance  in  my  practice  an 
infant  of  eighteen  months  was  suddenly  seized  with  eclampsia,  and  the 
mother  in  her  fright  mistaking  the  directions,  gave  thirty  grains  of 
bromide  at  one  dose.  Two  hours  afterward,  when  I  was  able  to  attend, 
I  found  that  the  convulsions  had  ceased  at  once,  and  that  the  ])atient 
was  playful.  Such  cases  show  the  innocuousness  of  a  large  dose  of  the 
bromide,  and  the  safety  in  administering  the  medicinal  dose  often. 

In  severe  cases  the  bromide  does  not  always  act  with  sufficient  prompt- 
ness and  poAver.  The  hydrate  of  chloral  should  then  be  em]doyed, 
given  by  the  mouth  or  dissolved  in  two  or  three  drachms  of  water,  and 
given  with  a  small  glass  or  gutta-percha  syringe  per  rectum.  If  used 
in  sufficient  quantity  ^^cr  rectum,  and  retained  by  pressure  with  a 
napkin,  it  is  quickly  absorbed,  and  will  usually,  in  about  fifteen  or 
twenty  minutes,  control  the  movements.  For  a  child  of  one  year  I 
employ  about  two  grains,  and  for  one  of  four  years  four  grains,  given 
by  the  mouth,  or  double  this  quantity  given  per  rectum.  With  the 
use  of  the  measures  indicated  above,  eclampsia  is,  in  my  practice, 
mucli  more  amenable  to  treatment  than  in  former  years.  Unless  the 
cause  be  such  that  recovery  is  impossible  from  the  very  nature  of  the 
case,  the  convulsions  will  soon  cease  with  these  measures.  It  is  inter- 
esting to  observe  the  effect  of  the  chloral  enema.  In  from  five  to  ten 
minutes  the  convulsive  movements  cease  in  the  muscles  of  the  flice,  a 
moment  later  in  those  of  the  arms,  and  lastly  in  those  of  the  loAver 
extremities. 

But  additional  treatment  may  be  required,  according  to  the  path- 
ological state  which  has  brought  on  the  eclampsia.  If  it  be  an  eruptive 
fever,  as  scarlatina,  and  the  eruption  have  receded,  active  revulsive 
measures,  as  hot  mustard  baths,  are  required ;  if  in  dysentery,  or  other 
internal  inflammation,  the  flaxseed  and  mustard  poultice  should  be  ap- 
plied over  the  parts  affected. 

In  those  dangerous  cases  in  Avhich  symptoms  of  cerebral  congestion 


TETAXUS    IXFAXTUM.  435 

continue  after  the  eclampsia  ceases,  additional  treatment  is  required. 
The  child  remains  drowsy,  does  noL  spaak,  or  apparently  suffer  in  any 
way,  and  the  pupils  act  less  readily  than  in  health.  It"  this  condition 
remain  after  the  lapse  of  a  fow  hours,  there  is  probably  serous  effusion. 
All  attacks  of  eclampsia,  unless  the  mildest,  are  followed  by  a  period 
of  drowsiness,  but  the  persistence  of  it,  with  sj^mptoms  which  indicate 
hyperiemia,  with  perhaps  effusion  within  the  cranium,  calls  for  the  em- 
ploym.Mit  of  additional  mL"asures.  Vesication  by  cantharidal  collodion 
should  then  be  produced  behind  the  ears,  mild  revulsives  be  applied  to  the 
extremities,  the  head  kept  cool,  the  bowels  open,  and,  in  certain  cases, 
a  diuretic  like  iodide  of  potassium  may  be  advantageously  employed. 
The  utmost  care  should  be  enjoined  in  reference  to  the  hygienic  man- 
agement of  those  who  are  subject  to  eclampsia.  The  diet  should  be 
nutritious,  but  bland,  and  all  causes  of  excitement  be  studiously  avoided. 


CHAPTER    XII. 

TETANUS  INFANTUM. 

Tetanus  or  trismus  is  one  of  the  most  interesting  diseases  of  in- 
fancy. It  is  first,  in  point  of  time,  in  the  long  catalogue  of  fatal  mala- 
dies. It  occurs  suddenly  and  unexpectedly  in  the  robust  as  Avell  as 
feeble,  almost  certainly  destroying  life  within  a  few  hours  under  modes 
of  treatment  heretofore  employed.  It  is  more  frequent  in  some  locali- 
ties and  conditions  of  life  than  in  others.  In  New  York  it  is  more 
comm:)n  than  tetanus  at  any  other  age,  or,  indeed,  in  all  other  ages, 
since  the  mortuary  statistics  of  this  city  exhibit  a  larger  number  of 
deaths  from  this  disease  in  the  first  year  of  life  than  subsequently. 
Infantile  tetanus  occurs,  with  very  few  exceptions,  in  the  newborn. 

Interesting  and  important  as  is  tetanus  infantum,  it  must  be  con- 
fessed that  our  knowledge  of  it  is  much  more  limited  and  imperfect  than 
it  should  be,  when  we  consider  ■what  great  advancement  has  beL'U  made 
in  pathological  inquiries  during  the  present  century.  Our  information 
in  reference  to  its  causation,  symptoms,  and  proper  treatment  is  not 
much  in  advance  of  that  of  M.  Dazille,  or  Dr.  Joseph  Clarke,  whc 
lived  in  tlie  latter  part  of  the  last  century. 

Did  we  better  understand  the  patliology  of  diseases  in  the  newborn, 
or  coidd  we  more  accurately  ascertain  tlie  condition  of  organs  at  this 
age,  doubtless  we  should  occasionally  consider  those  phenomena  which 
we  now  designate  as  a  disease  per  se,  under  the  title  tetanus,  as  symp- 
toms of  some  other  affection.  But  as  tetanic  rigidity  and  spasms  in 
the  newborn  occur  so  abruptly,  masking  all  other  symptoms,  and  ordi- 
narily endin'x  in  death,  without  our  knowin<f  certainly  whether  or 
not  there  is  any  antecedent  disease,  it  seems  })roper  that  we  fchoulu 


i86  TETANUS    INFANTUM. 

recognize  the  state  in  which  such  muscuUir  rigidity  occurs  with  such  a 
rapid  result  as  an  independent  affection.  This  explanation  is  required 
from  the  fact  that  I  have  added  to  the  accompanying  table  one  case 
from  Billard,  which  this  observer  relates  under  the  head  of  spinal  men- 
ingitis. In  this  case,  an  infant  three  days  old  was  attacked  with  con- 
vulsions.  "  His  limbs  were  rigid  and  violently  bent ;  the  muscles  of 
the  face  were  in  a  continual  state  of  contractitm."  On  the  following 
day  "  the  convulsions  continued ;  .  .  .  the  body  remained  rigid, 
and  the  vertebral  column,  Avhich  the  Aveight  of  the  trunk  will  cause  to 
bend  with  the  greatest  ease  in  a  young  infant,  remained  straight  and 
immovable  Avhenever  the  child  was  raised."  At  the  autopsy,  in  ad- 
dition to  meningeal  apoplexy,  Avhich  is  often  present  in  those  Avho  die 
of  tetanus  infantum,  a  thick  pellicular  exudation  was  found  upon  the 
spinal  arachnoid.  There  is,  therefore,  a  strict  accordance  of  the  symp- 
toms and  history  of  this  case  with  those  which  other  observers  descrilje 
as  examples  of  tetanus  infantum  ;  moreover,  as  a  satisfactory  reason  for 
including  this  case  in  our  statistics,  certain  observers,  as  Ave  shall  see, 
have  reported  epidemics  of  tetanus  in  which  meningitis  was  the  principal 
lesion. 

Fatal  Cases. 

Case     1.  Male ;  taken  when  three  days  old ;  lived  sixty  hours.     Labatt, 

Edin.  Med.  and  Surg.  Jour.,  April,  1819. 
"       2.  Female  ;  taken  when  three  days  old  ;  lived  forty  hours.     Ibid, 
"       3.  Taken  Avhen  five  days  old  ;  lived  fifty  hours.     Ibid. 
"       4.  Taken  Avhen  three  days  old  ;  lived  one  day.     Ibid. 
"       5.  Male ;    taken  when  tAVo  days  old ;    lived  tAvo  days.      Billard, 

Treatise  on  Diseases  of  Children,  Stewart's  trans.,  p.  477. 
"       G.  Male ;  taken  when  three  days  old  ;  lived  two  days.     Romberg-. 
"       7.  Male ;  taken  when  six  days  old  ;  lived  ninety-three  hours.     Dr. 

Imlach,  Monih.  Jour,  of  Med.  SeL,  Aug.  1850. 
"       8.  Female ;  taken  at  five  days ;  lived  four  days.     Caleb  Woodworth, 

M.D.,  Boston  Med.  and  Surg.  Jour.,  Dec.  18,  1831. 
"       9.  Negro;  taken  at  seven  d-iys;  lived  twenty-four  hours.     P.  C. 

Gaillard,  M.D.,  South.  Jour,  of  Med.  and  Phar.,  Sept.  1846. 
"     10.  i\Iale  ;  taken  Avhen  seven  days  old  ;  lived  one  day.     Augustus 

Eberle,  ^SI.D.,  Missouri  Med.  and  Surg.  Jour.,  1847. 
"     11.  Taken  Avhen  seven  days  old.     D.  B.  Nailer,  K  0.  Med.  Jour., 

Nov.  1846. 
"     12.  Male;  taken  AA'hen  three  days  old;  lived  one  day.     N.  0.  3Ied. 

a)id  Surg.  Jour.,  May,  1853. 
*'     13,  Negro;  taken  Avhen  three  daA's  old ;  lived  three  days.     Robert 

H.  Clunu,  M.D.,  N.  0.  Med.  and  Surg.  Jour. 
"     14.  Taken  Avheu  two  days  old ;  died  in  four  hours  after  the  doctor's 

visit.     Ibid. 
"     15.  Taken  Avhen  scA^en  days  old  ;  lived  one  day.     C.  H.  Cleaveland, 

New  Jersey  Med.  Rq).,  April,  1852. 
"     10.  Negro  ;  taken  Avhen  seven  days  old  ;  death  finally.     Greenville 

Dijwell,  Amer.  Jour,  of  Med.  and  Sci.,  Jan.  1863. 
"  .  17.  Taken  Avhen  twelve  days  old ;  lived  one  day,     Thomas  C.  Bos- 

Avell,  communicated   to  Dr.   Sims,  Amer.  Jour,  of  Med.    Sci., 

1846. 


PERIOD    OF    COMMENCEMENT.  487 

Case  18.  Taken  when  about  five  days  old ;  died  at  about  the  age  of  nine 
days.     B.  R.  Jones.     Ibid. 

"  19.  Taken  at  or  soon  after  birth  ;  lived  two  days.  Dr.  Sims,  ^l»ier. 
Jour,  of  Med.  Sci,  Aj^ril,  184(3. 

"     20.  Taken  at  the  age  of  six  days ;  lived  one  day.     Ibid. 

"     21.  Taken  Avhen  three  days  old  ;  lived  two  days.     Ibid. 

"  22.  Male  ;  taken  at  the  age  of  eight  days ;  died  in  three  hours. 
Communicated  to  the  writer. 

"  23.  Taken  at  the  age  of  twelve  hours ;  lived  two  days.  Communi- 
cated to  the  writer. 

"  24.  Female ;  taken  when  seven  days  old ;  lived  forty-five  hours. 
The  writer. 

"  25.  Male  ;  taken  at  the  age  of  seven  days ;  lived  about  forty-eight 
hours.      Ibid. 

"     2G.  Female  ;  taken  at  the  age  of  eight  days  ;  lived  three  days.    Ibid. 

"     27.  Female  ;  taken  at  the  age  of  five  days;  lived  three  days.    Ibid. 

"     28.  Female  ;  taken  when  four  days  old ;  lived  two  days.     Ibid. 

"     29.  Taken  when  six  days  old  ;  died  next  day.     Ibid. 

"     30.  Taken  when  five  days  old  ;  lived  twenty-four  hours.     Ibid. 

"     31.  Taken  when  eight  days  old  ;  lived  two  days.     Ibid. 

"     32.  Male  ;  taken  when  five  days  old  ;  lived  one  day.     Ibid. 

Favorable  Cases. 

Case  1.  Kegro  ;  female  ;  taken  when  three  days  old  ;  recovered  in  a  few 
davs.  Kobert  S.  Baily,  Charleston  Med.  Jour,  and  Rev.,  Nov. 
1848. 

"  2.  Xegro ;  taken  at  eleven  davs;  recovered  in  fifteen  davs.  W. 
B.  Lindsay,  N.  0.  Med.  Jour.,  Sept.  1846. 

"  3.  Negro  ;  taken  when  ten  days  old  ;  recovered  in  thirty-one  days. 
P.  C.  Gaillard,  Charleston  Med.  Jour,  and  Rev.,  Nov.  1858. 

"  4.  iNIale  ;  taken  at  the  age  of  eight  davs  ;  recovered  in  twentv-eight 
days.     Ibid. 

"  5.  Negro;  taken  at  seven  days;  recovered  in  fifteen  days.  Au- 
gustus Eberle,  Mi'^-^ntiri  Med.  and  Surrj.  Jour.,  1847. 

"  6.  Taken  when  eight  days  old  ;  recovered  in  four  weeks.  Furlong, 
Ed  in.  Med.  and  Surf/.  Jour.,  Jan.  1830. 

"  7.  Taken  at  the  age  of  one  week ;  recovered  in  two  days.  Dr. 
Sims,  Amer.  Jour,  of  Med.  Sci.,  April,  1846. 

"  8.  Female  ;  taken  at  the  age  of  three  days ;  recovered  in  five  weeks. 
The  writer. 

Period  of  Co.mmencemext. — Finckh,'  who  saw  cases  of  tetanus  of 
the  newborn  in  the  Stuttgart  Hospital,  states  that  it  began  in  one  case 
on  the  second  day  after  birth,  in  eight  on  the  fifth,  and  in  seven  on  the 
seventh. 

Professor  Cedersclijold,  of  Stockholm,  treated  forty-two  cases  in  lios- 
pital  practice  in  1H34,  and  in  these  cases  it  usually  commenced  between 
tiie  ages  of  four  and  six  days.  Copland'  says  that  it  gt'tierally  com- 
mences in  tlie  first  seven  or  nine  days  after  birth,  and  rarely  later  than 
tlie  fourteenth.  Romberg  states  that  it  commences  between  the  fifth 
and  nintli  days.     In  two  hundred  cases  observed  by  Reicke,  in  Stutt- 

'  Hecker's  Annalen,  vol.  iii.,  No.  3,  p.  304.  *  Medical  Dictionary. 


488  TETANUS    INFANTUM  . 

gart,  in  the  course  of  forty -two  years,  it  ■svas  never  found  to  commence 
before  the  fifth,  rarely  after  the  ninth,  and  never  after  tlie  eleventh  day, 
Schneider  says  that  the  disease  occurs  oftenest  between  the  second  and 
seventh,  and  rarely  after  the  ninth  day.  In  six  cases  reported  by  Dr. 
C.  Levy,  of  Copenhagen,  it  began  in  two  on  the  third  day,  in  two  on 
the  fifth,  and  in  two  on  the  sixth.  Dr.  Greenville  Dowell,  Avho  has 
seen  much  of  tetanus  infantum  among  the  negroes  in  ^Mississippi  and 
Texas,  says  it  is  almost  sure  to  come  on  between  the  fifth  and  twelfth 
days  after  birth.  In  the  forty  cases  embraced  in  the  above  table,  the 
disease  began  as  follows: 

Age.  Casee. 

Under  two  days        ..........  2 

Two  days  ...........  1 

Til  ree  days 9 

Four  days         ...........  2 

Five  days 6 

Six  days  ...........  3 

Seven  days       ...........  8 

Eight  days        ...........  6 

Ten  days 1 

Eleven  days      ...........  1 

Twelve  days     ...........  1 

Very  rarely,  as  will  be  seen  hereafter,  tetanus  begins  at  or  so  soon 
after  birth,  that  it  may  properly  be  called  congenital. 

Frequency  in  Certain  Localities. — Tetanus  infantum  occurs 
probably  in  all  countries,  but  it  does  not  greatly  increase  the  mortality 
except  in  certain  localities.  Some  of  the  British  and  Continental 
physicians,  whose  observations  of  disease  have  been  ample,  confess  that 
they  have  seen  so  few  cases  that  they  have  almost  no  personal  knowl- 
edge of  this  malady.  On  the  other  hand,  there  are,  or  have  been, 
places  in  every  zone  where  it  is  or  has  been  so  prevalent  as  to  check  sen- 
sibly the  increase  of  population.  The  attention  of  the  profession,  more 
than  a  half  century  since,  was  directed  to  the  prevalence  of  tetanus  in 
the  Island  of  Heimacy,  off"  the  coast  of  Iceland.  On  this  island  scarcely 
an  infant  escaped,  while  on  the  mainland  scarcely  one  was  affected. 
Heimacy,  the  product  of  volcanic  action,  of  small  extent  and  almost 
destitute  of  vegetation,  supports  a  scanty  population.  The  inhabitants 
live  chiefly  on  the  flesh  and  eggs  of  the  sea- fowl,  and  are  filthy  and 
degraded  in  their  habits.  About  the  year  1810,  the  Danish  govern-, 
nient  deputed  the  landjyJiysicus  of  Iceland  to  visit  Heimacy,  and  ascer- 
tain the  nature  of  the  disease  which  Avas  so  destructive  to  the  infants. 
Although  this  gentleman,  from  his  brief  stay,  saw  no  case  himself,  he 
obtained  interesting  particulars  in  reference  to  the  disease  from  the 
priests  and  parents.  At  this  time  scarcely  an  infant  escaped.  Again, 
according  to  Dr.  Schleisner,  Avhose  report  in  reference  to  the  same 
locality  Avas  published  forty  years  later,  tetanus  Avas  still  the  most  fatal 
of  all  infantile  maladies. 

Tetanus  infantum  is  also  represented  as  very  fiital  in  the  Island  of 
St.  Kilda,  off  the  coast   of  Scotland.     In   the   temperate   regions  of 

'  Anier.  Jour,  of  Med.  Sci.,  Jan.  1863. 


CAUSES.  489 

America  and  Europe  cases  are  not  frequent,  except  occasionally  in  the 
poor  quarters  of  cities,  in  foundling  hospitals,  and  rarely  in  country 
towns  where  the  conditions  are  favorable  for  its  occurrence.  The 
records  of  the  Dublin,  Stuttgart,  and  Stockholm  lying-in  asylums  fur- 
nish many  cases.  In  the  town  of  Fulda,  Germany,  in  1802,  Dr. 
Schneider  saw  six  cases  in  fourteen  days,  while  a  midwife  in  the  same 
place  stated  that  she  had  seen  more  than  sixty  in  nine  years. 

But  the  greatest  mortality  from  tetanus  infantum  is  in  the  warm 
climates,  both  of  the  Eastern  and  Western  Hemispheres.  In  the  West 
Indies,  the  southern  portion  of  the  United  States,  the  equatorial  regions 
of  South  America,  and  in  the  islands  of  Minorca  and  Bourbon,  it  has, 
in  many  localities,  been  the  most  frequent  and  fatal  of  infantile  maladies. 

It  is  an  interesting  fact  that  in  the  warm  regions  of  the  United  States 
the  victims  are  chietl}^  negro  infants.  L.  S.  Grier,  *  M.D.,  of  INIississippi, 
says :  "  The  first  form  of  disease  ■which  assails  the  negro  among  us  is 
trismus.  The  mortality  from  this  disease  alone  is  very  great.  No  sta- 
tistical record,  we  suppose,  has  ever  been  attempted,  but  from  our  indi- 
vidual experience  we  are  almost  willing  to  affirm  that  it  decimates  the 
African  race  upon  our  plantations  within  the  fii'st  week  of  independent 
existence.  Wc  have  known  more  than  one  instance  in  which,  of  the 
births  for  one  year,  one-half  became  the  victims  of  this  disease,  and  that, 
too,  in  spite  of  the  utmost  watchfulness  and  care  on  the  part  of  both 
planter  and  physician.  Other  places  are  more  fortunate,  but  all  suffer 
more  or  less ;  and  the  planter  who  escapes  a  year  without  having  to 
record  a  case  of  trismus  nascentium  may  congratulate  himself  on  being 
more  favored  than  his  neighbors,  and  prepare  himself  for  his  own  allot- 
ment, which  is  surely  and  speedily  to  arrive."  Dr.  Wooten^  says  :  "It 
is  a  disease  of  fatal  frequency  on  the  cotton  plantations  in  this  section  of 
Alabama."     He  has,  however,  never  seen  a  white  child  affected  with  it. 

While  tetanus  infantum  prevails  in  regions  wide  apart,  and  present- 
ing very  diverse  climatic  conditions,  there  is  a  similarity  as  regards  the 
personal  and  domiciliary  habits  of  the  people  who  suffer  most  from  its 
occurrence.  It  occurs  chiefly  among  those  who  are  filthy  and  degraded 
in  their  liabits,  who  live,  either  from  choice  or  necessity,  in  neglect  of 
sanitary  requirements.     This  fact  aids  us  in  an  understanding  of  the — 

Causes. — That  uncleanliness  and  inqiure  air  are  causes  of  tetanus 
is  as  fully  demonstrated  as  most  facts  in  the  etiology  of  diseases.  The 
attention  of  the  profession  was  forcibly  directed  to  this  cause  by  Dr. 
Joseph  Claike  in  a  paper  read  before  the  Royal  Irish  Academy  in  1789. 
This  ])hysician  Avas  in  charge  of  the  Dublin  Lying-in  Asylum,  and  had 
rightly  concluded  that  the  mortality  among  the  newborn  infants  was 
due  to  imperfect  ventilation.  Through  his  advice,  apertures,  twenty- 
four  inclies  by  six,  Avere  made  in  the  ceiling  of  earh  ward  ;  three  holes, 
ail  inch  in  diameter,  Avcre  bored  in  each  Avindow  frame  ;  the  upper  jiart 
of  the  doois  leading  into  the  gallery  Avere  also  perforated  Avith  sixteen 
one-inch  apertures,  and  the  number  of  beds  Avas  reduced.  Tiie  results 
of  these  simple  sanitary  regulations  may  be  seen  from  Dr.  Clarke's  oavd 

'  N.  O.  Med.  iukI  Surg.  Joiirn.,  Mav,  18"j4. 
»  Ibid.,  May,  le4(j. 


490  TETAXUS    INFANTUM. 

Statement.  He  says  :  "  At  the  conclusion  of  the  year  1782,  of  17,650 
infants  born  alive  in  the  Lying-in  Hospital  of  this  city.  2944  had  died 
Avithin  the  first  fortnight,  that  is,  nearly  every  sixth  child."  The  dis- 
ease in  nineteen  cases  out  of  twenty  was  tetanus.  After  the  wards 
were  better  ventilated,  namely,  from  17S2  till  the  time  of  the  prepara- 
tion of  Dr.  Clarke's  paper,  80o3  children  were  born  in  the  hospital,  and 
only  4!9  in  all  had  died,  or  about  one  in  nineteen.  So  impressed  was 
Dr.  Every  Kennedy,  who  at  a  later  period  had  charge  of  the  same 
asvlum,  with  the  belief  that  Dr.  Clarke  had  discovered  the  true  cause, 
and  had  been  able  in  great  measure  to  prevent  it,  that  he  enthusias- 
tically writes:  "  If  we  except  Dr.  Jenner,  I  know  of  no  ]jhysician 
Avho  has  so  far  benefited  his  species,  making  the  actual  calculation  of 
human  life  saved  the  criterion  of  his  improvements."  The  cases  occur- 
ring in  my  own  practice  have  almost  all  been  in  tenement-houses,  where 
habits  of  cleanliness  are  not  observed,  and  I  have  not  yet  seen,  in  the 
practice  of  others,  nor  heard  of  a  case  which  occurred  in  the  better  class 
of  domiciles.  The  statements  of  physicians  in  the  Southern  States,  who 
speak  from  extensive  observation  among  negroes,  are  strongly  corrobo- 
rative of  the  belief  that  the  disease  is  in  great  measure  due  to  unclean- 
liness  and  lack  of  pure  air. 

Dr.  Greenville  Dowell,  of  Texas,  states  that  he  has  been  able  to  trace 
tetanus  infantum  to  the  bedclothes,  saturated  with  excrementitious  mat- 
ters, Avhich  are  found  in  the  negro  cabins.  In  a  paper  published  by 
Prof.  John  M.  Watson,'  the  frequency  of  this  disease  among  negroes 
is  accounted  for  as  follows  : 

"  When  called  to  see  their  children,  we  find  their  clothes  wet  around 
their  hips,  and  often  up  to  their  armpits,  with  nrine.  .  .  .  The 
child  is  thus  presented  to  us,  when,  on  examination,  we  find  the  um- 
bilical dressings  not  only  wet  Avith  urine,  but  soiled,  likewise,  with  feces, 
freely  giving  off  an  offensive  urinous  and  fecal  odor,  combined  at  times 
with  a  gangrenous  fetor  arising  from  the  decomposition,  not  desiccation, 
of  the  cord." 

Another  cause  is  believed  to  be  some  irritation  in  the  intestines,  as 
from  retained  meconium.  Observers  in  the  Southern  States  and  else- 
Avhere  occasionally  mention  this  as  a  cause.  In  one  case  treated  by 
myself,  there  was  obstinate  constipation  immediately  before  the  attack, 
and  in  another  diarrhoea  preceded,  and  was  the  only  apparent  cause. 

In  certain  cases  the  assignable  cause  is  exposure  to  wet  or  cold,  or  to 
a  variable  temperature,  Avhich,  it  is  known,  occasionally  causes  tetanus 
in  the  adult.  Prof  Cederschjold  attributed  the  epidemic  which  he 
observed  in  Stockholm  to  a  sudden  change  of  temperature  irom  hot 
Aveather  in  ^lay,  to  frosty  in  June.  In  a  case  related  by  Dr.  P.  C. 
Gaillard,^  the  disease  commenced  as  follows  :  The  nurse  came  in  with 
wet  apron  and  clothes,  in  the  evening;  a  short  time  after  she  had  taken 
the  child  into  her  lap,  it  sneezed  violently  tAvo  or  three  times.  At  10 
p.  M.  tetanus  began.  In  certain  localities  on  the  continent,  where 
there    are    no    parish    churches,  the   frequent  occurrence    of   tetanus 

*  Nashville  Journ.  of  Med.  and  Surg.,  June,  1851. 

*  iSouthern  Jour,  uf  Med.  and  Pharmacy,  Sept.  1846. 


CAUSES.  49 1 

has  been  attributed  bv  physicians  to  the  practice  of  carrving  infants 
to  a  distance  to  be  christened,  thus  exposing  them  to  winds.  In  this 
city  I  have  observed  tetanus  after  a  similar  exposure.  The  influ- 
ence of  the  weather  in  the  production  of  tetanus  of  the  newborn  is  also 
shown  by  facts  observed  in  the  Stuttgart  Hospital.  In  an  aggregate 
of  twenty-five  cases  treated  in  that  institution,  all  but  three  occurred  in 
the  cold  months.  In  the  Island  of  Cayenne,  at  a  hamlet  surrounded, 
bv  mountains  and  dense  foresis,  tetanus  attacked  only  one  in  eveiy 
twelve  or  fifteen  of  the  infants.  After  a  great  part  of  the  forests  had 
been  cut  down,  so  as  to  allow  access  to  the  cold  sea  winds,  almost  all 
the  newborn  infants  fell  victims  to  tetanus.     [Insel,  Cayenne^) 

Hein  relates  that  a  citizen  of  Berlin  lost,  successively,  two  children 
with  tetanus  soon  after  birth.  When  the  second  child  fell  ill  he  ob- 
served that  its  cradle  was  exposed  to  a  current  of  air.  At  the  third 
accouchement  the  position  of  the  cradle  was  changed  and  the  infant 
escaped.  Exposure  to  wet  and  cold  has  been  long  recognized  as  a  cause 
of  the  disease.  According  to  Sauvages,  "  Hie  morbus  hieme  ct  cum 
aura  humida  s?epius  advenit  quam  sicca  sestate.'"^ 

The  causes  of  infantile  tetanus  enumerated  above  may  be  proximate 
or  remote,  may  produce  the  disease  by  their  direct  effect  on  the  system 
or  indirectly  by  causing  a  pathological  state  which  in  turn  leads  to  the 
development  of  the  disease.  There  are  other  direct  causes,  namely, 
organic  affections.  In  the  bodies  of  the  newborn  who  die  of  tetanus, 
lesions  are  observed  which  doubtless  result  from  the  spasms.  Again, 
others  are  found  which,  from  their  nature,  cotild  not  be  a  result,  and 
which,  being  observed  in  different  cases,  are  to  be  regarded  as  causes. 
The  most  frequent  of  such  lesions  is  inflammation  of  the  umbilicus  or 
umbilical  vessels, 

Mosciiion,  who  lived  in  the  first  century  of  the  Christian  era,  stated 
in  writings  still  extant  that  stagnant  blood  in  the  umbilical  vessels 
sometimes  produced  dangerous  disease  in  the  newborn  infixnt,  and  it  is 
supposed,  though  this  is  doubtful,  that  he  referred  to  tetanus.  In 
modern  times  the  attention  of  the  profession  has  been  more  particularly 
directed  to  this  cause  by  a  paper  published  by  Dr.  Colles.^  The  obser- 
vations contained  in  this  paper  were  made  in  the  Dublin  Lying-in 
Hospital  during  a  period  of  five  years.  In  each  of  these  years  he 
witnessed  from  three  to  five  post-mortem  examinations  in  cases  of 
infantile  tetanus,  and  the  lesions,  he  states,  Avere  in  all  much  alike,  as 
follows:  The  floor  of  the  umbilical  fossa  was  lined  by  a  membrane 
apparently  formed  by  suppurative  inflammation,  and  in  the  centre  of 
this  fossa  was  a  large  papilla.  This  papilla  consisted  of  a  soft  yellow 
substance,  apparently  the  product  of  inflammation,  and  in  all  the  cases 
the  umbilical  vessels  were  in  contact  with  this  substance  and  were  j)er- 
vious.  In  a  few  instances  superficial  ulcerations  were  found  near  the 
mouth  of  the  umbilical  vein,  and  occasionally  the  skin  surrounding  the 
umbilicus  was  raised.  The  peritoneum  covering  the  vein  was  highly 
vascular,  often  not  to  a  greater  distance  than  an  inch  above  the  umbili- 

1  Xosdl.  M.-thnd,  vol.  i.  p.  r)3l. 

«  Dublin  liuspital  Reports,  vol.  i.,  1818. 


492  TETAXUS    INFANTUM. 

cus,  but  sometimes  as  far  as  the  fissure  of  the  liver.  The  peritoneum 
in  the  course  of  the  umbilical  arteries  presented  the  inflammatory  ap- 
pearance in  still  greater  degree,  sometimes  as  far  as  the  sides  of  the 
bladder.  The  connective  tissue  lying  along  the  arteries  and  urachus 
anteriorly  was  loaded  with  a  yellow  watery  fluid.  The  inner  surface 
of  the  umbilical  vein  was  not  inflamed,  but  its  coats,  in  general,  were 
.thickened.  On  slitting  open  the  arteries,  a  thick  yellow  fluid,  resem- 
bling coagulable  l3anph,  was  found  within  their  coats,  and  in  all  cases 
these  vessels  were  thickened  and  hardened  as  far  as  the  fundus  of  the 
bladder. 

Dr.  Finckli,  who  observed  twenty-five  cases  in  the  Stuttgart  Hos- 
pital, believes  that  the  most  frequent  cause  was  suppuration  or  ulcera- 
tion of  the  umbilical  cord.  In  ten  of  the  twenty-five  cases  the  navel 
was  dry  and  cicatrized  ;  in  the  remainder  it  was  either  wet  or  swollen, 
with  a  bluish-red  inHamed  edge  at  the  margin  of  the  navel ;  a  dirty 
viscid  pus  covered  the  umbilical  depression. 

Dr.  Levy,  physician  of  the  Foundling  IIos})ital  in  Copenhagen, 
attended  twenty-two  cases  in  that  institution  in  1838  and  1839.  Of 
these  twenty  died,  and  fifteen  were  examined  carefully  after  death. 
In  fourteen  there  were  decided  marks  of  inflammation  of  the  umbilical 
arteries,  especially  of  those  portions  lying  along  the  urinary  bladder ; 
in  several  cases  the  peritoneum  over  the  arteries  was  much  injected,  and 
in  three  adherent  either  to  the  omentum  or  intestine  by  coaguhildc 
lymph ;  the  coats  of  the  arteries  were  thickened,  their  cavities  dilated 
and  containing  dark  reddish-brown  or  greenish  puriform  matter,  always 
fetid.  Sometimes  the  arterial  tunica  interna  was  found  ulcerated  and 
absent  in  places,  and  there  was  spongy  thickening  of  the  subjacent  con- 
nective tissue.  In  two  cases  the  ulcerative  process  had  extended  from 
the  tunica  interna  to  the  peritoneum,  and  there  was  a  deposit  of  thick 
ichorous  matter  around  the  ulcer;  in  one  case  both  arteries  were  so 
softened  that  their  coats  were  scarcely  distinguishable,  and  in  another 
these  vessels  had  become  gangrenous.  The  appearance  of  the  undjilicus 
was  unchanged  in  four  cases;  in  ten -the  fundus  was  red  and  filled  with 
puriform  fluid,  which  quickly  reappeared  when  removed,  and,  in  general, 
shortly  before  death,  the  navel  jjresented  a  greenish  color. 

According  to  Romberg,  Dr.  Scholler  made  ])Ost-mortem  examinations 
in  eighteen  cases  of  tetanus  infantum,  and  in  fifteen  found  inflammation 
of  the  umbilical  arteries.  These  vessels  were  swollen  near  the  bladder, 
in  one  case  to  the  diameter  of  four  lines,  and  were  found  to  contain  pus. 
The  lining  membrane  was  eroded  or  covered  with  an  alhuminous  exu- 
dation. Both  arteries  were  not  always  equally  inflamed,  and  in  three 
cases  only  one  was  affected. 

Schneeman^  found  minute  points  of  suppuration  in  the  umbilical  vein 
in  eight  cases,  and  pus  throughout  the  course  of  this  vessel  in  one. 

The  observations  mentioned  above  were  made,  for  the  most  part,  in 
hospitals  on  the  Continent ;  but  similar  observations  have  been  made 
in  private  practice.     M.  Borian, "  of  the  Isle  of  Bourbon,  says  that  he 

1  Holscber's  Anniilen,  vd.  v.  p.  4S4,  1840. 
«  Gazette  Medicale,  Pari>,  July  H,  1841. 


CAUSES.  493 

has  found  in  every  case  inflammation  around  the  umbilicus.  Dr.  John 
Furlonge,  ^  who  resided  at  St.  John's,  Antigua,  attributes  the  disease  to 
improper  dressing  of  the  umbilicus.  The  same  opinion  is  expressed  by 
Mr.  Maxwell,^  who  also  saw  the  disease  in  the  West  Indies.  Dr. 
Kansom  ^  states  in  a  communication  to  Prof.  John  M.  Watson,  that  he 
has  never  seen  a  case  of  tetanus  of  the  newborn  in  which  the  umbilicus 
was  healthy.  In  a  case  related  by  Robert  S.  Bailey,  *  there  was  a  hard 
scab  on  one  side  of  the  umbilicus,  and  tliis  part  was  much  distended.  A 
discharge  followed  the  removal  of  the  scab  and  the  child  recovered.  In 
a  favorable  case,  related  by  W.  B.  Lindsay^  the  umbilicus  Avas  tumid, 
and  not  disposed  to  heal.  Dr.  II.  0.  Wooten^  attributes  the  disease  to 
the  condition  of  the  umbilicus  and  umbilical  vessels,  and  states  that  he 
has  found  the  umbilicus  gangrenous.  A  case  has  been  reported  in 
which  the  umbilical  vessels  Avere  blocked  up  by  purulent  matter.^ 
Ivobert  H.  Chinn,^  jNI.D.,  of  Brazoria,  Texas,  believes  one  cause  of  the 
disease  to  be  improper  tying  and  management  of  the  umbilical  cord,  by 
which  a  diseased  state  is  produced,  which  extends  to  the  umbilicus  and 
thence  to  the  viscera.  At  a  meeting  of  the  Obstetrical  Society  of 
Edinburgh,  held  April  24,  18o0,  Dr.  Imlach  related  a  case  in  which 
there  was  a  dark  and  gangrenous  appearance  on  the  integument  around 
the  umbilicus,  and  the  peritoneum  underneath  Avas  also  dark  but  not 
inflamed;  umbilical  vein  healthy;  a  little  fibrin  in  the  left  umbilical 
artery ;  right  umbilical  artery  much  diseased ;  its  tAvo  inner  coats  ap- 
parently destroyed,  and  in  their  place  a  yellow  pultaceous  slough,  in 
Avhich  pus-globules  Avere  discovered  Avith  the  mjcroscope. 

It  is  evident  that  the  pathological  state  of  the  umbilicus  and  umbilical 
vessels  described  above,  and  Avhich  has  been  noticed  by  so  many  ob- 
servers in  different  countries,  cannot  result  from  the  tetanus.  It  is  pos- 
sible that  the  purifjrm  substance  noticed  in  the  umbilical  vessels  Avas 
disintegrated  fibrin,  Avhich  had  coagulated  at  the  time  of  ligation  of  the 
cord,  and  the  cells  seen  by  Dr.  Imlach  and  others  may  sometimes  have 
been  Avhite  corpuscles  still  remaining  from  the  stagnated  blood.®  Still 
the  evidences  of  inflammation,  in  at  least  a  part  of  the  cases  related 
above,  Avere  of  a  positive  character. 

Tiie  belief  that  um})ilical  lesions  occasionally  cause  tetanus  infantum 
comports  Avith  the  Avell-knoAvn  traumatic  causation  of  tetanus  in  the 
adult.  This  belief  is  strengthened  by  the  fiict,  Avhich  Avill  appear  further 
on  in  our  remarks,  that  tetanus  of  the  ncAvborn,  from  being  frequent  in 
certain  localities,  has  become  infrequent  through  greater  care  in  dress- 
ing and  manajiing  the  umbilical  cord. 

But  tllere  are  cases  of  tetanus  infantum  in  Avhich  there  is  no  disease 
in  or  about  the  umbilicus.  Dr.  Finckli,  of  Stuttgart,  examined  the 
umbilical  vessels  in  eleven  cases  Avithout  discovering  any  pathological 

'  Edin.  Med.  and  Surg.  Joiirn.,  Jan.  1830. 

'  Jr.maifa  PIiy>.  Jnurn.,  copied  into  ihe  London  Lancet,  April  11,  18')6. 

'  Nu.shvillc!  .Joiirn  ,  of  Med.  and  Suri;.,  June,  18.51. 

♦  Charleston  Med.  Journ.  and  Rev.,  Nov.  1848. 

&  N.  O.  .Med.  and  Surg.  Journ.,  Sept.  1846.  «  Ibid.,  May,  1840. 

T  Ibid.,  Mav  1.  lS.-).3.  »  Ibid.,  Sept.  1854. 

'  Virchow's  Ceilul.  Pathol. 


494  TETAXUS    INFANTUM. 

change.  Dr.  Samuel  B.  Labatt, '  master  of  the  Dubhn  Lying-in  Hos- 
pital, published  a  paper  entitled  "An  Inquiry  into  an  Alleged  Connec- 
tion between  Trismus  Nascentium  and  certain  Diseased  Appearances  in 
the  Umbilicus."  This  paper  Avas  designed  as  a  reply  to  the  essay  ol' 
Dr.  Colics.  Dr.  Labatt  relates  several  cases  in  which  there  was  no 
disease  of  the  umbilicus  and  umbilical  vessels,  and  others  in  which  the 
disease  was  so  slight  that  it  probably  produced  no  injurious  effect  on 
the  health  of  the  child.  Dr.  James  Thompson, '  who  s})ent  considerable 
time  in  the  tropical  regions,  says:  "I  have  myself  examined  nearly 
forty  cases  of  infants  that  have  sunk  under  this  complaint.  In  many  I 
have  looked  at  no  other  part  but  the  navel,  and  have  found  it  in  all 
states ;  sometimes  perfectly  healed,  especially  if  the  infants  had  lived 
several  days ;  at  other  times  a  simple  clean  wound.  When  death 
occurred  on  tlie  fifth  or  sixth  day,  the  wound  was  frequently  in  a  raAV 
state.  I  never  yet  saw  it  in  a  sphacelated  condition."  This  writer 
concludes  from  his  observations  that  there  are  cases  in  which  the  cause 
is  located  elsewhere  than  in  the  umbilicus  or  ural)ilical  vessels.  Dr. 
John  Breen  ^  remarks :  "  From  dissections  .  .  .  we  have  never 
been  able  to  discover  any  peculiar  morbid  appearance  which  would 
justify  us  in  offering  any  explanation  of  the  pathology  of  the  disease." 
In  my  own  cases  there  was  no  evidence  of  disease  of  the  umljilicus  or 
umbilical  vessels  so  far  as  could  be  ascertained  by  external  examination, 
and  in  one  (No.  32)  a  careful  post-mortem  examination  disclosed  no 
lesion  of  these  parts. 

The  inference  from  the  above  observations  is  that,  although  umbilical 
disease  may  be  an  occasional,  pi-obably  not  infrequent,  cause  of  tetanus 
infantum,  cases  occur  in  which  such  disease  is  not  present,  and  we  must 
look  for  the  cause  elsewhere.  From  the  nature  of  tetanus  infmtum, 
the  cerebro-spinal  axis  has  been  from  time  to  time  examined  in  those 
who  have  died  of  this  malady,  and  occasionally  sufficient  cause  has  been 
found  in  this  part  of  the  system. 

I  have  alluded  in  another  connection  to  a  case  from  Billard,  in  which 
tetanic  rigidity  occurred  in  an  infant  three  days  old,  as  the  I'csult  of 
spinal  meningitis.  That  tonic  spasms  not  infre(|uently  occur  in  older 
children  in  consequence  of  meningeal  inflammation  is  well  known,  and 
in  some  of  the  reported  epidemics  of  infantile  tetanus  meningitis  was 
really  present,  and  was  doubtless  the  cause  of  the  tonic  spasms.  Such 
an  epidemic  was  observed  by  Professor  Cederschjold  in  Stockholm,  in 
1834.  AVitliin  a  few  months  he  treated  forty-tAvo  cases,  and,  in  ad- 
dition to  the  lesions  wliich  are  known  to  result  from  tetanus,  there  was 
found  in  the  bodies  examined  a  plastic  exudation  at  the  base  of  the 
brain.  Finckh,  of  Stuttgart,  made  tAventy  post-mortem  examinations 
of  those  who  had  died  of  this  disease,  and  in  nine  found  spinal  menin- 
geal inflammation. 

Meningitis  in  the  newborn  is,  however,  rare,  and  we  must  regard  it 
as  an  exceptional  cause  of  tetanus. 

1  Edin.  Med.  and  Surg.  Jouni.,  April,  1819. 

»  Ibid.,  Jan    1822. 

»  Dub.  Journ.  of  Med.  and  Chem.  Sci.,  Jan.  1836. 


CAUSES.  495 

In  1846  there  appeared  from  the  pen  of  Dr.  Sims,  then  practising  at 
Montgomery,  Ahibama,  a  paper  designed  to  show  that  tetanus  of  the 
newborn  is  produced  by  ])ressure  exerted  on  the  nervous  centre,  through 
depression  of  the  occipital  bone.  In  1848  the  same  writer^  pubhshed  a 
paper,  fully  enunciating  his  theory  as  follows :  "  That  trismus  neona- 
torum is  a  disease  of  centric  origin,  depending  on  a  mechanical  jjressure 
exerted  on  the  medulla  oblongata  and  its  nerves ;  that  this  pressure  is 
the  result,  most  generally,  of  an  inward  displacement  of  the  occipital 
bone,  often  very  perceptible,  but  sometimes  so  slight  as  to  be  detected 
with  difficulty  ;  that  this  displaced  condition  of  the  occiput  is  one  of  the 
fixed  physiological  laws  of  the  parturient  state ;  that  when  it  persists  for 
any  length  of  time  after  birth  it  becomes  a  pathological  condition,  capa- 
ble of  producing  all  the  symptoms  characterizing  trismus  neonatorum, 
Avhich  are  instantly  relieved  simply  by  rectifying  this  abnormal  dis- 
placement, and  thereby  removing  pressure  from  the  base  of  the  brain." 
In  both  papers  cases  are  narrated  in  support  of  this  theory,  but  there 
are  serious  objections  to  this  mode  of  explaining  the  occurrence  of  the 
disease.  In  the  first  place,  if  this  explanation  were  correct,  tetanus 
ought  ordinarily  to  occur  sooner,  for  the  occiput  is  as  much  depressed 
posteriorly,  and  in  the  majority  of  cases  more  depressed  at  birth  than 
at  the  period  when  it  does  ^ictually  commence.  Pressure  on  the  medulla 
would  certainly  be  followed  by  immediate  and  marked  symptoms,  in- 
stead of  an  immunity  for  four  or  five  days. 

Again,  well-known  facts  in  reference  to  the  causation  of  tetanus 
infantum  conflict  with  Dr.  Sims's  theory',  as,  for  example,  epidemics  of 
the  disease,  its  prevalence  in  one  locality  and  absence  in  another, 
although  no  particular  attention  be  given  to  the  position  of  the  infant, 
the  diminution  of  the  number  of  cases  by  greater  attention  to  cleanli- 
ness, of  which  there  is  abundant  proof.  Moreover,  there  are  many 
reported  cases  of  this  disease  at  the  commencement  of  which  there  was 
no  perceptil)le  displacement  of  the  occipital  bone. 

The  ine([uality  of  the  cranial  bones  often  observed  in  tetanus  infan- 
tum should,  in  my  opinion,  be  explained  as  follows  :  When  the  newborn 
infimt  becomes  emaciated  the  volume  of  the  brain  is  diminished,  like 
that  of  the  trunk  or  limbs,  and  the  sinking  of  the  occipital  bone  simply 
corresponds  with  the  amount  of  waste  in  the  cerebral  substance.  What- 
ever the  disease  in  the  young  infant,  if  there  be  much  emaciation,  the 
parietal  bones  will  usually  be  found  more  prominent  than  the  occipital. 
Now,  in  fatal  tetanus  infantum  emaciation  is  very  rapid ;  those  fleshy 
and  plump,  if  the  disease  do  not  speedily  end,  become  pinched  and 
wrinkled.  Viewed  in  this  light,  the  occipital  depression  should  be 
regarded  as  a  result,  and  not  a  cause,  of  the  tetanus. 

Although  we  do  not  accept  the  theory  which  attributes  tetanus  in- 
fantum to  occipital  depression,  there  are  a  few  cases  on  record  in  which 
it  was  apparently  due  to  injury  of  the  licad  received  at  birth.  Dr.  Sims 
has  related  one  such  case,  that  of  a  negro  infant.  The  mistress,  an 
observing  lady,  gave  to  Dr.  Sims  the  folloAving  account  of  it :  Its  head 
was  *' mightily  mashed.     .     .     .     The  bones  seemed  to  be  loose.     I 

1  Amer.  Jmir.  of  MeJ.  Sci. 


496  TETAXUS    IXFAXTUM. 

got  it  to  take  a  little  lioiled  milk  on  the  first  day  ;  but  it  swalloAved 
very  little  and  very  badly,  for  its  jaws  seemed  to  be  locked.  On  the 
next  day  it  took  spasms  and  got  stiff'  all  over;  its  hands  "were  shut  up 
tight,  and  its  arms  were  bent  up  so  (she  placed  her  forearms  at  right 
angles).  Every  time  I  touched  it  the  spasm  Avould  get  Averse  all  over, 
screwing  up  its  face  till  it  was  the  ugliest  thing  in  the  Avorld  ;  and  when 
the  spasms  Avore  oft'  it  looked  as  well  as  any  other  newborn  baby.  But 
then  the  stiff"ness  never  left  it,  and  the  spasms  kept  coming  and  going  till 
it  died."     It  lived  two  days. 

It  is  evident,  from  the  description  given  by  the  mistress,  that  this 
was  a  case  of  tetanus  commencing  at  or  so  soon  after  birth  that  it 
seemed  almost  congenital.  The  apparent  cause  w^as  injury  of  the  head, 
occurring  in  consequence  of  protracted  birth,  the  infant  being  resusci- 
tated Avith  difficulty  after  several  minutes. 

Dr.  W.  C.  Sutton^  published  a  similar  case.  The  infant  at  birtli  was 
apparently  dead,  but  was  resuscitated  so  as  to  live  eighteen  hours  in  a 
state  of  tetanic  rigidity.  In  cases  in  Avhicli  tetanus  begms  at  birth, 
doubtless,  the  cerebro-spinal  axis  is  in  some  way  affected ;  but  in  the 
absence  of  post-mortem  examinations,  the  exact  nature  of  the  lesion  is 
uncertain. 

It  is  evident,  therefore,  that  in  this  disease,  as  in  eclampsia,  the  cause 
in  diff'crent  cases  may  be  entirely  distinct.  Dr.  James  Johnson,  many 
years  ago,  expressed  his  belief  in  the  multiplicity  of  causes,  and  he  had 
been  a  careful  and  intelligent  observer  in  the  West  Indies. 

The  causes  may  be  arranged  in  tAvo  groups,  one  external,  the  other 
internal.  In  the  first  group  should  be  placed  imperfect  A'cntilation, 
personal  and  domiciliary  uncleanliness,  and  atmospheric  vicissitudes  ;  in 
the  second  group,  so  fir  as  ascertained,  inflammation  of  the  umbilicus 
and  umbilical  vessels,  meningitis,  and,  rarely,  injury  of  the  cerebro- 
spinal axis  during  birth. 

The  lesions  resulting  from  tetanus  infantum  pertain  chiefly  to  the  cir- 
culatory system.  In  the  cases  examined  by  Professor  Cederschjold,  of 
Stockholm,  already  alluded  to,  the  meningeal  and  cerebral  vessels,  and 
those  of  tlie  spinal  cord,  the  cavities  of  the  heart,  and  the  largo  vessels 
connected  Avith  the  heart,  Avere  distended  Avith  blood. 

Finckh  made  post-mortem  inspection  of  twenty  cases  in  the  Stuttgart 
Hospital,  the  bodies  at  death  having  been  placed  on  their  faces,  in  order 
to  prevent  any  deceptive  appearance  from  tlie  gravitation  of  blood.  In 
four  he  filled  to  detect  any  alteration  in  the  spinal  cord  or  its  mem- 
branes, but  in  the  remaining  sixteen  he  found  effusion  of  blood,  in  con- 
siderable quantity,  the  Avhole  length  of  the  spinal  cord,  betAveen  the 
bony  Avails  and  the  dura  mater.  It  should  be  stated,  hoAvever,  that 
spinal  meningeal  inflammation  Avas  present  in  nine  of  the  sixteen,  though 
the  extniA%asation  did  not,  probably,  result  from  the  inflammation,  but 
fi-om  the  tetanus.  The  blood  in  Finckh's  cases  Avas  very  dark,  some- 
times fluid,  at  other  times  coagulated.  In  one  case  no  change  Avas 
ob.served  in  the  appearance  of  the  brain  or  its  membranes.  In  the 
remaining  nineteen,  more  or  less  extra vasated  l)lood  Avas  found  on  the 

1  Xa^^hvillo  Jour,  of  Med.  and  .Surg.,  April,  18.53. 


CAUSES.  497 

surface  of  the  brain,  or  in  its  interior.  The  substance  of  the  brain  was 
healthy,  as  also  its  membranes,  except  the  congestion.  The  only 
abnormal  appearance  obsei'ved  in  the  thoi'acic  and  abdominal  viscera 
was  strong  contraction  of  some  portion  of  the  intestinal  tube  in  five 
cases.  Dr.  West  says  :  "  The  most  frequent  post-mortem  appearances 
in  these  cases" — referring  to  tetanus  infantum — "and  that  which  I 
found  in  the  bodies  of  all  the  four  children  whom  I  observed,  consist 
of  effusion  of  blood,  either  fluid  or  coagulated,  into  the  cellular  tissue 
surrounding  the  theca  of  the  cord.  Conjoined  with  this  there  is  gener- 
ally a  congested  state  of  the  vessels  of  the  spinal  arachnoid,  and  some- 
times an  effusion  of  blood  or  serum  into  its  cavity.  The  signs  of  con- 
gestion about  the  head  are  less  constant,  though  much  oftener  present 
than  absent,  and  sometimes  existing  in  an  extreme  degree ;  Avhile  in 
one  instance  I  found  not  merely  a  highly  congested  state  of  the  cerebral 
vessels,  but  also  an  effusion  of  blood,  in  considerable  quantity,  between 
the  skull  and  dura  mater,  and  also  a  slighter  effusion  into  the  arach- 
noid cavity."'  Dr.  Weber,  of  Kiel,  also  placed  on  their  flices  infants 
who  had  died  of  tetanus,  and,  without  exception,  found  injection  of  the 
capillaries  of  the  cord  and  spinal  meninges  and  extravasation  of  blood. 
M.  Matuszvnski,  according  to  Bouchut,  "has  observed  effusions  of 
blood  of  variable  quantity,  in  the  cerebral  pia  mater,  in  the  ventricles, 
and  in  the  choroid  plexuses,  with  considerable  injection  of  the  mem- 
branes of  the  brain.  He  has  also  seen  serous  infiltration  beneath  the 
arachnoid,  and  serous  effusion  into  the  ventricles,  accompanied  by  a 
diminution  of  the  consistence  of  the  cerebral  substance."  In  two  cases 
examined  by  myself  there  was  intense  injection  of  the  cerebral  men- 
inges and  of  the  meninges  of  the  upper  part  of  the  spine,  but  no 
extravasation  Avas  noticed.  The  spinal  canal  Avas  not  opened.  In  a 
tliird  case,  in  Avhich  the  spinal  canal  Avas  opened,  there  Avas  extra,A'asa- 
tion  in  addition  to  the  congestion  ;  this  Avas  especially  observed  along 
the  spinal  theca. 

Dr.  H.  0.  Wooten^  states  that  he  has  made  seA^eral  post-mortem 
examinations,  and  has  found  the  pathological  appearances  as  uniform 
as  in  anv  other  disease,  as  folloAvs :  "Engorgement  of  the  substance  of 
the  brain,  and  of  the  meninges  lining  the  base  of  the  brain,  the  medulla 
oblongata,  and  spinal  marroAV ;   liver  congested." 

In  a  case  related  by  Dr.  Imlach  before  the  Edin.  Obst.  Soc,  April 
24,  iHoO,  the  upper  part  of  the  lungs  avus  healthy,  the  posterior  portion 
congested,  and  containing  many  dark  points ;  heart  and  liver  healthy  ; 
small  intestines  of  a  light  broAvn  color;  stomach  and  large  intestines 
p  illid  ;   there  had  been  umbilical  hemorrhiige. 

Rymberf;  states  that  he  found  in  a  child  Avhose  death  occurred  from 
this  disease,  such  intense  congestion  of  the  veins  and  sinuses  of  the 
brain,  that  a  slight  touch,  and  the  removal  of  the  cranial  bones,  ])r(»- 
ducel  extravasation  of  the  partly  coagulated  and  jiartly  fluid  blood. 
Dr.  Scholler,  on  the  other  hand,  found  extravasation  of  blood  in  the 
spinal  canal  in  only  one  case  in  eighteen. 

It  is  seen  from  the  above  observations,  that  tetanus  of  the  infant  is 

1  N.  O.  Med.  and  Siir-    J.uir.,  :\ray,  184(3. 
32 


498  TETANUS    IXFAXTUM. 

ordinarily  accompanied  by  great  passive  congestion,  which  is  especially 
marked  in  tlie  cercbro-spinal  axis,  and  that  frequently  extravasations 
occur  from  the  distended  capillaries.  The  embarrassment  of  respira- 
tion and  the  retarded  circulation  of  blood  consequent  on  the  tetanic 
rigidity,  afford  sufficient  explanation  of  this  state  of  the  vessels. 

Sympto.ms. — In  many  cases  premonitory  symptoms  are  absent,  or 
are  so  slight  as  to  escape  notice.  In  some  jjaticnts  fretfulness  precedes 
the  attack,  but  no  more  than  is  often  observed  in  those  who  continue 
in  good  health.  The  first  symptom  which  alarms  the  parents,  and  shows 
the  grave  nature  of  the  commencing  disease,  is  inability  to  nurse,  or 
evident  pain  and  hesitation  in  nursing.  Commencing  with  rigidity  of 
the  masseters,  the  disease  gradually  extends  to  the  other  voluntary 
muscles,  and  in  the  course  of  a  few  hours  the  muscles  of  the  limbs,  as 
well  as  of  the  trunk,  are  involved.  Persistent  muscular  contraction, 
Avhich  is  the  pathognomonic  feature  of  infantile  tetanus,  is  developed  not 
fully  in  the  beginning,  but  by  degrees  in  each  affected  muscle,  so  that 
it  is  not  till  after  the  lapse  of  several  hours,  perhaps  even  a  day,  that 
the  greatest  amount  of  rigidity  is  attained.  Therefore,  in  the  commence- 
ment of  tlie  disease,  the  limbs  can  be  bent,  and  the  jaw  pressed  open, 
more  readily  than  at  a  subsequent  stage,  though  with  manifest  jiain  to 
the  infant. 

During  the  period  of  maximum  rigidity,  the  jaws  are  fixed  almost 
immovably,  often  with  a  little  interspace  between  them,  against  which 
the  tongue  presses,  and  in  which  frothy  saliva  collects.  The  head  is 
thrown  backward  and  held  in  a  fixed  ]»osition  by  the  stiffness  of  the  cer- 
vical muscles.  The  forearms  are  flexed  ;  the  thumbs  are  thrown  across 
the  palms  of  the  hands,  and  are  firmly  clenched  by  the  fingers ;  the 
thiglis  are  drawn  toward  the  trunk ;  the  great  toes  are  adducted,  and 
the  other  toes  flexed.  Occasionally  opisthotonos  residts  from  the  ex- 
treme contraction  of  the  dorsal  and  posterior  cervical  muscles.  The 
infimt  can  sometimes  be  raised  without  any  yielding  of  the  muscles,  by 
one  hand  under  the  occiput  and  the  other  under  the  heels. 

The  rigidity  is  liable  to  variation  in  its  intensity,  even  after  the  full 
development  of  the  disease.  If  the  infant  be  quiet,  especially  if  asleep, 
the  muscles  are  partially  relaxed  to  such  an  extent  sometimes,  in  the 
first  stages  of  the  complaint,  that  the  features  have  a  placid  and  natural 
expression,  though  only  for  a  short  time.  Frecjuent  exacerbations 
occur  in  the  muscular  contraction,  sometimes  without  any  apparent 
cause,  and  sometimes  produced  by  anything  which  excites  or  disturbs 
the  child.  Attempts  to  open  the  lips  or  jaws,  or  eyelids,  or  to  bend 
the  limbs,  blowing  on  the  face,  or  even  the  crawling  of  a  fly  upon  it, 
occasions  the  paroxysm. 

During  the  paroxysm  the  eyelids  are  forcibly  compressed,  as  well  as 
the  lips,  wliich  are  either  drawn  in  or  are  pouting;  tlie  forehead  and 
cheeks  are  thrown  into  wrinkles,  and  the  physiognomy  is  indicative  of 
great  suffering.  The  unnatural  positions  of  the  trunk  and  limbs,  which 
result  from  the  muscular  contraction,  are  increased  for  the  moment;  the 
head  is  more  forcibly  thrown  back,  and  the  limbg  more  strongly  flexed. 
The  muscular  movements  Avhich  occur  during  the  paroxysms  arc  some- 
times described  as  clonic  spasms.     There  is  indeed  occasionally  some 


SYMPTOMS.  -199 

quivering  of  the  limbs,  and  yet,  as  I  have  on  different  occasions  noticed, 
so  far  from  the  muscidar  action  being  a  clonic  spasm,  it  is  clearly  tonic, 
and  is  intensified  during  the  paroxysm.  In  fatal  cases  the  paroxysms 
occur  more  and  more  frequently  until  the  period  of  collapse. 

The  crying  of  the  child  affected  by  tetanus  is  never  loud,  however 
great  the  sufiering.'  It  is  variously  described  by  writers  as  "  whimper- 
ing "  or  "  whining."  It  is  of  this  suppressed  character  in  consequence 
of  the  rigid  state  of  the  respiratory  muscles  and  their  imperfect  move- 
ment. 

During  the  exacerbation  respiration  is  suspended,  or  so  imperfect, 
and  the  circulation  so  retarded,  that  the  surface  becomes  of  a  deep  red, 
almost  livid,  color.  Sometimes  epistaxis  occurs,  affording  partial  relief 
to  the  congestion,  and  sometimes,  though  less  frequently,  the  blood 
forces  itself  from  the  congested  liver  along  the  umbilical  vein,  and  escapes 
from  tlie  umbilicus.  The  intense  passive  congestion  consequent  on  the 
tetanic  spasm  is  general  throughout  the  system,  but  extravasation  of 
blood  appears  to  be  more  common  around  the  brain  and  spinal  cord 
than  elsewhere. 

The  frequency  of  tlie  pulse  and  respiration  varies  in  different  cases, 
and  at  different  staijes  of  the  same  case.  Thev  are  often  somewhat  ac- 
celerated,  but  at  other  times  are  natural,  or  are  even  slower  than  in 
health. 

While  the  appetite  of  the  infant,  to  appeai-ance,  is  not  diminished, 
the  pain  which  it  experiences  in  nursing  is  such  that  alimentation  is 
necessarily  deficient.  It  can  be  fed  with  a  spoon  for  a  time  after  it 
ceases  to  take  food  in  the  natural  way,  but  artificial  feeding  soon  fails. 
The  milk  placed  in  its  mouth  is  in  great  part  pressed  back  through  the 
violence  of  the  spasm  which  is  induced  by  the  attempt  to  feed  it. 

In  consequence  of  imperfect  nutrition,  the  infant  rapidly  wastes  away. 
There  is  no  other  disease,  except  the  diarrhoeal  affections,  in  which  the 
emaciation  is  so  rapid.  In  a  case  related  by  Dr.  W.  B.  Lindsa}^,'  the 
record  states  that  "the  iiifint  was  f^it  three  days  before,  but  was  now 
emaciated."  Romberg,  who  saw  tetanus  infantum  in  European  liospi- 
tals,  and  Dr.  Robert  H.  Chinn-,  of  Texas,  both  speak  of  the  rapid  ema- 
ciation. The  trunk  and  extremities  lose  their  fulness,  and  the  features 
become  pinched.  Several  observers  have  noticed  the  appearance  of 
miliaria  in  tliis  reduced  state  of  system,  especially  around  the  shoulders, 
and  sometimes  a  decidedly  icteric  hue  appears  on  the  skin. 

The  condition  of  tlie  intestines  is  not  uniform.  They  may  be  relaxed, 
particularly  if  the  disease  be  due  to  some  irritation  in  them  ;  in  other 
cases  the  stools  are  natural  or  constipated. 

It  is  often  difficult  to  ascertain  the  state  of  the  eyes,  since  attempts 
to  open  the  eyelids  bring  on  spasms  and  cause  firm  compression  of  the 
hds  against  each  other.  According  to  Sir  Henry  Holland,  one  of  the 
first  symptoms  which  occurred  in  cases  on  the  island  of  Heimacy  was 
strabismus,  with  rolling  of  the  eyes.  But  this  statement  must  be  re- 
ceived with  caution,  since  these  cases  were  not  seen  by  any  physician, 

1  N.  O.  Mfd.  .Jonr.,  Sept.  1840. 

»  N.  O.  Mod.  and  Surg.  Jour.,  Sept.  1854. 


500  TETANUS    INFANTUM. 

and  the  informarion  was  obtained  from  the  parents  and  priests.  If  true, 
the  proximate  cause  of  the  disease  in  Heimaey  would  seem  to  be  located 
in  the  cerebrospinal  axis.  Contraction  of  the  pupils  commonly  occurs 
in  the  stage  of  collapse. 

Mode  of  Death. — Death  in  infantile  tetanus  may  occur  from  apnoca 
in  the  paroxysms,  from  extreme  congestion  of  the  cerebral  vessels,  or 
apoplexy ;  and,  lastly,  it  may  occur  from  exhaustion.  The  last  mode 
is,  ])robably,  the  most  frequent. 

Prognosis. — All  writers  till  recently  agree  that  tetanus  of  the  infant 
rarely  terminates  flivorably.  Cullen  attributes  the  ignorance  of  phy- 
sicians in  regard  to  this  disease  to  the  fict  that  it  is  so  little  amenable 
to  treatment  that  they  are  not  usually  summoned  to  attend  those  affected 
with  it.  In  the  Island  of  Heimaey,  of  one  hundred  and  eighty-five 
cases  occurring  during  a  series  of  years  about  the  commencement  of  the 
present  century,  not  one  survived;  and  in  the  same  locality,  at  West- 
mannoe,  a  small  islet,  sixty-four  per  cent,  of  all  the  infants  born  died  of 
trismus.  (Report  of  Dr.  Schleisner.)  Similar  statements  in  regard  to 
the  mortality  of  tetanus  infantum  are  given  by  physicians  in  the  Southern 
States.  Dr.  H.  0.  Wooten,^  of  Alabama,  says  that  he  has  "never  seen 
a  decided  case  of  tetanus  nascentium  that  did  not  prove  fatal, 
and  that  it  is  very  generally  deemed  useless  to  call  in  medical  aid  after 
the  initiatory  symptoms  are  well  declared."  Mr.  Maxwell,  ^  speaking 
in  reference  to  the  West  Indies,  says :  "From  observations  which  I 
have  made  for  a  series  of  years,  .  .  .  I  found  that  the  depopulat- 
ing influence  of  trismus  nascentium  Avas  not  less  than  twenty-five  per 
cent.  It  scarcely  has  a  parallel  within  the  bills  of  mortality."  Dr.  D. 
B.  Nailer^  savs  :  "  About  two-thirds  of  the  deaths  among  the  negro  chil- 
dren  are  from  this  disease,  and  so  uniformly  fatal  is  it,  that  a  physician 
is  never  sent  for." 

Yet  death  does  not  always  result.  Eight  of  the  forty  cases  in  my 
collection  recovered ;  but  a  correct  opinion  cannot  be  formed  from  this 
of  the  actual  ratio  of  fjivorable  to  unfavorable  cases,  since  flivorable  cases 
are  nmch  more  likely  to  be  published.  In  the  history  of  these  eight 
cases,  two  interesting  facts  are  noticed,  which,  when  present  may  serve 
as  a  ground  for  hope  of  a  successful  termination.  These  were,  the  age 
at  which  the  disease  began,  and  the  fluctuation  in  the  symptoms.  With 
two  exceptions,  the  infants  who  recovered  were  about  a  week  old  when 
the  initiatory  sym[)toms  apppeared,  and  there  were  fluctuations  in  the 
gravity  of  the  symptoms ;  whereas,  fatal  cases  ordinarily  grow  progres- 
sively worse.  Yet,  in  favorable  cases,  the  symptoms  are  never  so  severe 
as  they  become  in  a  few  hours  in  those  who  succumb. 

Duration  in  Fatal  Cases. — Of  eighteen  cases  observed  by  Finckh 
in  the  Stuttgart  Hospital,  fifteen  died  in  two  days,  two  in  five  days,  and 
one  in  seven  days.  During  the  epidemic  in  the  Stockholm  hospitals,  in 
1834,  where  forty-two  cases  were  treated,  the  disease  seldom  lasted  more 
than  two  days.     Romberg  says :  "  It  generally  lasts  from  two  to  four 

1  N.  0.  Mo<l    Journ  ,  May,  1846. 

*  .Jamaica  Phv*.  .Journ,  copierl  into  the  London  Lancet,  April  11,  1835. 

»  N.  O.  Med.  Journ.,  Nov.  1846. 


PREYEXTIVE    TREATMENT.  501 

days,  but  its  duration  is  at  times  limited  at  from  eight  to  twenty-four 
hours,  and  occasionally,  though  rarely,  it  extends  from  five  to  nine  days." 
In  thirty-one  fatal  cases  in  my  collection,  in  which  the  duration  is 
mentioned : 

One  lived        .........  3  hours. 

Eleven  otliers  lived        .......  1  day  or  less. 

Twelve  lived  ........  2  days. 

Four  lived.     .........  3  days. 

Three  lived    .........  4  days. 

Both  Underwood,  who  published  a  little  treatise  on  diseases  of  chil- 
dren in  1789,  and  Dr.  Elsa.sser,  at  a  more  recent  date,  record  fatal 
cases  which  were  unusually  protracted.  The  one  descriljed  by  Under- 
wood was  treated  in  the  British  Lying-in  Hospital,  and,  although  all 
the  others  treated  in  this  institution  died  by  the  third  day,  this  lived  si.x 
weeks ;  but  it  is  suggested  by  the  author  that  death  Avas  due  in  part  to 
some  other  affection.     The  child  treated  by  Elsiisser  lived  thirty-one  days. 

DuRATiox  IX  Favorable  Ca.se.s. — In  the  eight  flivorable  cases  in 
my  collection,  the  duration  of  the  disease,  reckoned  from  the  time  when 
the  infant  ceased  nursing  till  it  began  again,  was  as  follows  :  In  one  ca.se, 
two  days  ;  in  one,  a  few  days ;  in  one,  fourteen  days ;  in  two,  fifteen 
days ;  in  one,  twenty-eight  days ;  in  one,  twenty-one  days ;  and  in  the 
remainincj  case,  about  five  weeks. 

DiAGXCSis. — To  one  who  has  seen  this  disease  in  the  newborn,  or  is 
familiar  with  its  symptoms,  diagnosis  is  easy.  The  symptoms  which 
possess  diagnostic  value  are  more  manifest  and  reliable  than  in  most 
other  infantile  maladies.  Permanent  rigidit}'^  of  the  voluntary  muscles, 
with  temporary  exacerbations,  such  as  have  been  described  above,  which 
are  induced  by  any  cause  which  disturl)s  the  infant — as  attempts  to  open 
the  mouth  or  eyelids — is  pathognomonic. 

Prevextive  Tre.vimext. — While  tetanus  infantum,  if  fidly  devel- 
oped, is  ordinarily  fatal,  in  si)ite  of  any  remedial  measures  heretofore 
used,  there  is  no  doubt  of  the  eificacy  and  value  of  preventive  measures, 
when  ])ro])erly  employed.  This  was  shown  by  the  great  reduction  in 
mortality  in  the  Dublin  Lying-in  Hospital  through  the  thorough  ven- 
tilation introduced  by  Dr.  Clarke.  Dr.  Meriwether,'  of  Montgomery, 
Ala.,  says:  "  When  the  diseitse  appears  endemically  on  a  plantation,  it 
may  be  arrested  by  having  the  negro  houses  whitewashed  with  lime, 
inside  and  out ;  by  raising  the  floors  above  the  ground ;  by  removing 
all  filth  from  under  and  about  the  houses;  by  particular  attention  to 
cleanliness  in  the  bedding  and  clotlies  of  the  mother;  and  in  the  dress- 
ing of  tiie  child,  so  as  to  ))revent  any  of  the  matter  from  the  umbilicus 
lying  long  in  contact  with  the  skin."  Many  physicians,  especially  in 
the  .Southern  States,  speak  confidently  of  care  in  dressing  the  cord  and 
attention  to  the  umbilicus,  as  a  means  of  ])revention.  Grafton'*  says  that 
l>e  has  "•  never  known  the  disease  to  occur  in  any  child  whose  navel  had 
the  turpentine  dressing."     lie   uses  turpentine   as   follows:    "At  the 

1   A'ncr.  Journ.  <if  M^d.  S.-i.,  April,  1854. 
"  N.  O.  .Med.  and  Surg.  Ju.irn  ,  July,  1853. 


502  TETANUS    INFANTUM. 

first  time,  a  few  drops  of  undiluted  turpentine  are  applied  immediately 
to  the  umbilicus  around  the  cord,  and  it  is  anointed  at  every  succeeding 
dressing,  the  turpentine  being  diluted  one-half  or  two-thirds  Avith  olive 
oil,  lard,  or  fresh  butter."  This  use  of  turpentine  has  also  been  recom- 
mended by  other  practitioners  in  warm  regions. 

Dr.  John  Furlongc,'  of  St.  John's,  Antigua,  believes  that  no  case 
would"  occur  with  the  following  treatment :  "The  cord,  when  divided, 
should  be  wrapped  in  clean  linen.  Every  night,  for  two  weeks,  one  or 
two  drops  of  tinct.  oj)ii  and  spts.  vini,  equal  parts,  should  be  given,  and 
castor  oil,  with  a  little  magnesia,  every  morning.  The  child  must  be 
Avashed  in  tepid  water  every  morning,  and  the  funis  dressed."  If  this 
treatment  be  attended  by  the  success  which  is  claimed  for  it  by  Dr. 
Furlonge,  so  great  care  in  dressing  the  cord  is  certainly  well  repaid  in 
localities,  as  at  x-Vntigua,  Avhere  a  large  proportion  of  the  infants  die  of 
tetanus. 

Some  experienced  observers  go  so  far  as  to  assert  that  it  is  possible 
to  ward  off  tetanus  infantum  after  the  occurrence  of  premonitory  symp- 
toms. Dr.  DowelP  says :  '•'■  Some,  with  slight  twitchings  of  the  luus- 
cles,  have  recovered  without  any  trouble  by  being  put  into  a  mustard- 
bath  Avashed  clean,  and  put  in  a  clean  and  well-ventilated  cabin." 

Treatment. — In  considerino;  the  effect  of  medicinal  agents  Avhich 
have  been  employed  in  the  treatment  of  infantile  tetanus,  the  great 
difficulty  which  the  child  experiences  in  swallowing  should  be  borne  in 
mind.  Without  care,  a  considerable  part  of  the  dose  is  lost  by  the 
spasm  of  the  muscles  of  deglutition,  Avhich  ordinarily  occurs  Avhcn  the 
spoon  is  placed  in  the  mouth,  so  that,  unless  special  attention  be  given 
to  this  matter,  it  is  uncertain  whether  the  prescribed  dose  is  fully 
administered. 

The  treatment  employed  by  different  jihysicians  has  been  very 
diverse.  Antiphlogistic  remedies  were  prescribed  by  Finckh,  but  every 
case  so  treated  was  fatal.  He  states  that  Avhenever  blood  was  ab- 
stracted, even  in  small  quantities,  the  symptoms  were  aggravated.  The 
same  result  has  followed  depletory  measures  in  the  practice  of  other 
physicians. 

The  internal  remedies  Avhich  have  been  most  frequently  prescribed 
are  opiates  and  antispasmodics.  Furlonge,  in  a  favorable  case,  gave 
laudanum,  in  doses  of  one  dro])  every  three  hours,  alternately  with  two 
grains  of  Dover's  powder.  Woodworth  also  gave  one-drop  doses  of 
laudanum  ;  Eberle,  one-sixth  of  a  drop  hourly.  The  opiate  lias  gener- 
ally been  given  in  combination  Avith  an  antispasmodic.  The  Dover's 
powder,  given  every  three  hours  by  Furlonge,  Avas  combined  Avith  five 
grains  of  sulphate  of  zinc.  The  hourly  doses  of  laudanum,  by  Eberle, 
Avere  comljined  Avith  six  drops  of  tincture  of  asafoetida. 

When  anjiesthetics  began  to  be  employetl  in  the  treatment  of  diseases 
it  Avas  believed  that  they  Avould  be  especially  useful  in  cases  of  tetanus. 
Accordingly  chloroform  has  been  used  in  tetanus  in  the  infant,  Avith 
the  effect  of  controlling  the  spasm  during  the  time  of  its  use,  but  Avith- 

»  Edin.  Mod.  and  Siirir.  Joiirn.,  .Tan.  1830. 

*  Amer.  Jour,  of  tlie  Med.  Soi.,  January,  1863. 


TREATMENT.  503 

out  curing  tlie  disease.  In  Case  T  in  our  first  table  it  was  employed 
several  times,  but  apparently  "without  delaying  the  fatal  result.  The 
editor  of  the  Neiu  Orleans  Medical  and  Surgical  Journal  states,  in 
the  May  issue  of  that  periodical  for  18o3,  that  he  has  used  chloroform 
in  tetanus  infantum,  with  the  effect,  he  believes,  of  prolonging  life. 
AniBsthetics  certainly  relieve  the  suffering  of  the  infant,  and  on  this 
account,  even  if  they  do  not  prolong  life,  their  judicious  employment 
seems  proper. 

The  remedy  which,  in  my  opinion,  is  far  preferable  to  all  others,  is 
hydrate  of  chloral.  Since  the  introduction  of  this  agent  into  therapeu- 
tics, it  has  been  emplo^'ed  by  several  physicians  in  the  treatment  of 
this  disease  with  so  good  a  result  that  it  will  probably  supersede  all 
other  medicines  for  this  purpose.  Dr.  Widerhofer,^  of  Vienna,  states 
that  he  has  saved  six  out  of  ten  or  twelve  by  the  use  of  chloral.  He 
prescribes  it  in  doses  of  one  to  two  grains  by  the  mouth,  or,  if  there  be 
great  difficulty  in  swallowing,  two  or  four  grains  by  the  rectum.  Dr. 
F.  Auchenthales^  relates  a  case  in  which  he  gave  even  six-grain  doses, 
and  in  nine  days  the  disease  had  entirely  disappeared.  I  have  recently 
employed  hydrate  of  chloral  in  a  case  of  tetanus,  giving  it  in  half-grain 
doses,  every  two  hours,  except  wliL-n  there  was  profound  sleep.  The 
disease  was  fully  developed,  and  the  symptoms  severe  when  I  Avas 
called.  I  did  not  believe  that  the  infant  with  the  old  remedies  would 
live  more  than  tAvo  days,  but  by  the  chloral  life  was  prolonged  nearly 
one  week.  Moreover,  by  the  use  of  chloral  the  suffering  of  the  infiint 
is  greatly  diminished.  The  frequent  inhalation  of  sulphuric  ether  also 
aids  materially  in  controlling  the  spasms. 

The  administration  of  alcoholic  stimulants  is  requii'ed  at  short  inter- 
vals on  account  of  the  rapid  emaciation  and  great  prostration. 

Local  treatment  directed  to  the  umbilicus  in  those  cases  in  which 
there  is  evidence  of  inflammation  of  the  umbilicus  or  umbilical  vessels 
should  not  be  neglected.  The  application  of  an  emollient  poultice  to 
the  umbilicus  has  been  foUoAved  by  apparent  improvement,  if  Ave  may 
believe  the  statement  of  some  physicians  Avho  have  made  use  of  this 
treatment.  Dr.  Meriwether,  of  Alabama,  says,  if  there  bo  no  im- 
provement from  the  medicine  Avhich  he  orders,  he  applies  a  blister, 
larger  tlian  a  dollar,  to  the  umbilicus,  and  Avith  this  treatment  the 
child  generally  improA'es ;  a  remarkable  statement,  since  so  foAV  im- 
prove at  all. 

A  Avarm  foot-bath,  repeated  at  inter\'als  of  a  fcAV  hours,  and  stimu- 
lating embrocations  along  the  spine,  are  proper  adjuvants  to  the  treat- 
ment. 

^  Luiidori  Lancet,  March  18,  1871.  '  Jalir.  f.  Kinderheil.,  N.  S.,  iv. 


504  INTERNAL   CONVULSIONS. 


CHAPTER   XIII. 

INTERNAL  CONVULSIONS 

(^Spasin  of  the  Olottis.     Laryiujismus  St>-idulus.) 

YouxG  children  are  liable  to  temporary  suspension  of  respiration,  in- 
duced by  violent  emotions,  especially  by  anger.  In  the  midst  of  their 
excitement,  while  they  are  crying  or  screaming,  their  breath  is  suddenly 
held,  as  if  from  tonic  spasm  of  the  respiratory  muscles.  In  a  few  sec- 
onds respiration  returns  and  is  natural.  There  is  no  stridulous  inspira- 
tion or  other  unusual  sound,  and  there  is  no  apparent  ill-eftect,  unless 
occasionally  a  degree  of  languor.  External  convulsions,  Avhich  seem  to 
be  threatening,  seldom  occur,  and  when  they  do,  are  ordinarily  mild. 
Some  writers  consider  dentition  the  predisposing  cause  of  this  arrest  of 
respiration,  by  inducing  a  sensitive  state  of  the  nervous  system.  Such 
an  effect  of  dentition  is  possible,  but  certainly  many  infants  are  affected 
in  this  manner  before  the  age  of  dentition. 

A  much  more  serious  state,  and  one  which  is  recognized  as  a  true  dis- 
ease, is  that  variously  designated  by  writers  as  internal  convulsions, 
spasm  of  the  glottis,  child-crowing,  laryngismus  stridulus,  etc.  Mani- 
fest difficulties  attend  the  investigation  of  the  pathological  state  in  this 
disease.  There  can  be  little  doubt  that  it  is  not  precisely  the  same  in  all 
cases.  That  there  is,  during  the  paroxysms,  tonic  or  clonic  S})asm  of  more 
or  fewer  of  the  respiratory  muscles  is  inferred  not  only  from  the  symp- 
toms pertaining  to  the  respiratory  apparatus,  but  from  the  fact  that  in 
severe  cases  spasms  of  the  external  muscles,  as  those  of  the  limbs  and 
face,  often  occur.  Usually,  also,  the  movements  of  the  eyeballs  indi- 
cate spasmodic  contractions  of  the  motor  muscles  of  the  eyes.  The  fact 
of  spasmodic  muscular  action  in  parts  that  are  visible  justifies  the  belief 
that  it  occurs  in  other  parts  which  are  concealed  from  view,  especially 
as  the  characteristic  symptoms  cannot  be  readily  explained  except  on 
this  supposition.  Trousseau  says:  "Internal  convulsions  consist,  then, 
principally  in  a  spasm  of  the  diaphragm  and  of  the  respiratory  muscles 
of  tlie  abdomen  and  chest;  but  it  occurs,  also,  that  the  muscles  pertain- 
in"'  to  the  larvnx  are  affected  Avith  spasm  at  the  same  time  Avith  these." 
liilliet  and  Barthez  conclude  from  the  symptoms  that  the  "heait  is  not 
always  a  stranger  to  this  internal  convulsion,  Avhich,  perhaps,  prolongs 
itself  even  to  the  intestines."  The  nmsclcs  of  the  pharynx  appear  to 
be  involved,  in  some  cases,  as  well  as  those  of  respiration,  rendering 
deglutition  difficult.  In  one  form  of  internal  convulsions,  namely,  that 
wiiich  is  priiici]):dly  refei-rcd  to  l)y  Avriters,  there  is  not  complete  arrest 
of  respiration,  but  the  inspirations,  during  tlic  paroxysms,  are  difficult 
and  are  attended  by  a  stridulous  noise.  Again  the  res]»ii-ation  may 
cease  entirelv,  but  when  it  commences  it  is  stridulous,  and  difficult  during 


CAUSES.  505 

a  few  inspirations.  In  still  another  form  of  the  disease  respiration 
ceases,  but  there  is  no  symptom  or  sign  indicative  of  glottic  spasm  or  of 
an  obstacle  to  the  ingress  of  air ;  the  inspirations  which  succeed  the 
paroxysm  are  easy  and  noiseless.  It  has  been  suggested  that,  in  these 
cases,  there  is  paralysis  rather  than  spasmodic  contraction  of  the  respi- 
ratory muscles,  but  the  symptoms  may  be  explained  in  accordance  with 
the  commonly  accepted  opinion,  namely,  that  there  is  spasm  of  the 
diaphragm  and,  periiaps,  of  certain  muscles  of  the  chest  and  abdomen, 
while  the  laryngeal  muscles  are  not  aifected.  M.  Herard,  indeed,  Avho 
has  written  one  of  the  best  monographs  on  internal  convulsions,  describes 
three  forms  of  the  disease,  according  to  the  supposed  location  of  the 
spasm,  namelv,  laryngeal,  diaphragmatic,  and  another,  which  consists 
of  a  blending  of  the  two. 

Internal  convulsions  are  not  frequent  in  this  country  ;  they  are  rare 
in  France,  more  frequent  in  Germany,  and  quite  common  in  Englandt 
They  occur,  Avith  few  exceptions,  before  the  age  of  two  years.  Dr.  Wcs. 
observed  thirty-one  cases  under  the  age  of  two  years,  and  only  six  above 
that  age. 

Causes. — The  causes  of  internal  convulsions  are  not  fully  ascertained. 
Most  observers  have  remarked  the  relative  fre(|uency  of  the  disease  dur- 
ing the  period  of  dentition,  and  it  is  probable  that  dental  evolution  does 
operate  as  a  cause,  by  rendering  the  nervous  system  more  impressible. 

S])asm  of  the  glottis  has  been  attributed  to  enlargement  of  the  thymus 
gland,  and  also  to  enlargement  of  the  cervical  and  bronchial  glands.  It 
is  jtresumed  that  this  ell'ect  is  due  to  the  pressirre  of  these  glands  on  the 
par  vagum,  or  the  recurrent  laryngeal  nerve.  It  is  certain,  however, 
that  there  is  no  such  enlargement  of  the  thymus  gland  Avhich  could 
possibly  produce  glottic  spasm,  or  any  other  form  of  internal  convulsion 
at  the  age  at  which  these  convulsions  commonly  occur.  This  gland  is 
largest  in  the  newborn,  and  having  no  function  after  birth,  it  gradually 
becomes  atrophied.  If  an  enlarged  thymus  could  produce  glottic  spasm, 
it  would  certainly  occur  most  frequently  in  the  newborn.  Abnormal 
development  of  tlie  thymus  gland  seemed  to  be  the  cause  of  atelectasis 
in  two  infants  who  died  soon  after  birth  in  my  practice,  but  I  have  not 
seen  a  ease  in  which  a  convulsive  attack  was  referable  to  this  cause.  M. 
Herard  examined  the  thymus  gland  in  six  children  who  died  of  internal 
convulsions,  and  in  sixty  who  died  of  other  affections,  and  was  not  able 
to  discover  in  its  condition  any  causative  relation  to  this  disease.  Indeed, 
cases  have  been  reported  in  which  the  thymus  had  undergone  more  than 
its  usual  atrophy  at  the  time  when  the  convulsions  occurred  (Ilasse). 
Eidargements  of  the  lymphatic  glands  in  the  vicinity  of  the  pneumo- 
gastric  or  recurrent  laryngeal  nerve  may  possibly  give  rise  to  glottic 
si)asm,  but  tliis  is  doubtless  an  infrecjuent  cause,  if  it  be  a  cause  at  all, 
since  these  glands  arc  often  greatly  enlarged  in  strumous  and  tul)ereular 
diseases  without  such  a  result.  According  to  Dr.  Jacobi:'  "In  some 
cases,  described  by  Dr.  Friedleben,  a  congenital  hypertrophy  of  the 
thyr()i<l  gland  has  probably  been  the  cause  of  laryngismus.  The  patients 
were  newborn  infants  of  normal  development,  and  born  by  normal  labors. 

I  N.  Y.  Journ.  of  Mod  ,  Jan    1800. 


506  INTERNAL    CONVULSIONS, 

There  were  no  constitutional  causes  of  the  disease,  but  a  remarkable 
vascular  swelling  of  the  thyroid  gland.  Whenever  the  swelling  in- 
creased, the  veins  of  the  face  and  head  increased  in  size  also,  the  face 
grew  livid,  and  the  extremities  and  spinal  column  exhibited  slight  tonic 
convulsions.  The  recurrent  nerves  were  entirely  surrounded  by  the 
glandular  tissue,  tlieir  neurilemma  looked  iniusually  red,  and  their  func- 
tions were  probably  injured  during  the  occassional  swelling  taking  place 
during  lifetime."     (Jacobi.) 

The  cause  is  occasionally  located  in  the  cerebro-spinal  axis.  Thus 
Dr.  Coley  relates  a  case  in  Avhich  an  exostosis  arising  from  the  internal 
surface  of  the  occipital  bone  pressed  upon  the  cerebelbim,  wliilo  nothing 
abnormal  Avas  discovei'ed  in  other  organs.  Examjjles  are  also  related 
in  which  the  cause  was  located  in  the  spinal  cord.  Thus  IMarshall 
Hall  relates  the  case  of  a  child  with  spina  bifida,  who  was  attacked  with 
croup-like  convulsions  whenever  it  lay  so  as  to  press  on  the  tumor. 

Internal  convulsions  are  also  frefjuent  in  rachitic  softening  and  absorp- 
tion of  the  calvarium,  since,  when  tliis  is  present,  undue  pressure  occurs 
upon  the  brain,  by  the  weight  of  the  head  of  the  cliild  upon  the  pillow. 

In  some  patients  there  is  evidently  an  hereditary  predisposition  to 
this  disease ;  those  affected  belonging  to  families  in  which  a  tendency 
to  convulsive  maladies  is  manifested.  Thus  Toogood  states  that  five 
infmts  of  the  same  family  Avere  affected  with  spasm  of  the  glottis;  and 
Reid  relates,  on  tlie  authority  of  Powel,  that  of  thirteen  infants  of  the 
same  parents  oidy  one  esca})ed  internal  convulsions. 

The  common  predisposing  cause  is  an  excitable  state  of  the  nervous 
system,  often  associated  with  impaired  general  health.  Hence  the  dis- 
ease is  more  prevalent  in  cities,  where  antihygienic  conditions  abound, 
than  in  the  country.  Hence,  too,  the  frequent  improvement  when  the 
patient  is  removed  to  the  pure  and  bracing  air  of  the  country.  The 
use  of  insufficient  food,  or  food  of  a  bad  quality,  must  for  the  same  rea- 
son be  considered  a  cause,  since  it  leads  to  impoverishment  of  the  blood, 
and  renders  the  nervous  system  more  impressible.  Facts  mentioned  by 
Reid  and  others  show  conclusively  the  influence  of  premature  weaning, 
and  the  use  of  indigestible  or  otherwise  improper  aliment,  in  the  pro- 
duction of  this  disease. 

The  causes  enumerated  aljove  are  for  the  most  part  predisposing;  oc- 
casionally they  are  the  only  apparent  causes,  since  this  disease  some- 
times occurs  when  the  child  is  tranquil,  even  in  the  midst  of  quiet 
sleep,  or  when  it  is  at  rest  in  its  mother's  arms.  In  other  cases  and 
more  frecjuently,  there  is  an  exciting  cause,  often  trivial.  Anything 
that  requires  exertion  on  the  part  of  the  infant,  or  tliat  excites  strong 
emotions,  may  be  a  direct  cause,  as  anger,  or  any  of  the  violent  pas- 
sions; so  may  even  coughing,  or,  in  rare  instances,  attempts  to  swal- 
low. One  author  has  known  it  to  occur  from  excitement  produced  by 
examining  the  throat  with  a  spoon.  In  a  case  in  my  practice,  hereafter 
related,  it  occurred  whenever  the  infant  cried  violently.  It  appears 
from  the  above  facts  that  the  etiology  of  internal  convulsions  is  very 
similar  to  that  of  eclampsia.  The  same  spasmodic  muscular  contraction 
may  occur  from  a  variety  of  causes. 


SYMPTOMS.  507 

Anatomical  Characters. — While,  therefore,  structural  changes  in 
various  parts  of  the  system  may  give  rise  to  internal  convulsions,  this 
disease,  so  far  as  ascertained,  presents  no  anatomical  characters,  and 
must  consequently  be  considered  one  of  the  neuroses.  The  lesions  of 
the  respiratory  apparatus  which  are  seen  at  post-mortem  examinations, 
are  due  to  the  convulsions  or  are  coincidences.  Emphysema  has  some- 
times been  observed  as  a  result,  it  is  believed,  of  the  spasmodic  and  ir- 
resiular  respiration.  It  Avas  present  in  all  of  Herard's  cases,  and  Eilliet 
and  Barthez  consider  it  conmion  in  those  who  die  of  this  affection, 
althouudi  they  did  not  observe  it  in  any  of  their  cases.  Slight  emphy- 
sema in  the  upper  lobes  is,  however,  a  common  lesion  in  feeble  infants, 
whatever  the  diseases  of  which  they  die.  Therefore  its  occurrence  in 
internal  convulsions  is  probably  due  more  to  molecular  change  in  the 
lungs,  since  these  patients  are  cachectic,  than  to  the  irregular  breathing, 
which  is  only  momentary. 

In  fatal  cases  of  internal  convulsions  the  blood  is  darker  than  usual, 
from  an  excess  of  carbonic  acid ;  and  in  some  cases  the  cavities  of  the 
heart  and  large  vessels  are  engorged  Avith  blood ;  but  in  others  they  con- 
tain no  more  than  the  normal  amount.  More  or  less  passive  congestion 
occui'S  in  the  internal  organs ;  and  congestion  of  the  cerebral  vessels  is 
in  some  patients  so  great  that  transudation  of  serum  occurs. 

SvMPTo^rs. — I  have  said  that  the  symptoms  vary  according  to  the 
seat  and  function  of  the  muscles  which  are  affected.  There  is  genei'ally 
previous  ill-health.  The  child  is  drooping,  and  is  sometimes  restless  for 
days  before  the  disease  appears,  Finalh*,  if  the  muscles  of  the  glottis 
become  affected,  the  peculiar  crowing  sound  is  heard  now  and  then  dur- 
ing inspiration.  It  is  observed  especially  Avhen  the  child  is  crying  or  is 
agitated.  It  may  be  loud  and  well-defined  from  the  first,  but  in  most 
jtatients  it  comes  on  gradually,  so  that  several  days  elapse  before  its  full 
stridulous  cliaracter  is  developed.  The  attacks  are  more  frequent  and 
severe  at  night,  in  or  after  the  first  sleep,  than  in  daytime. 

Under  favorable  hygienic  conditions,  the  malady  may  pass  off  Avith- 
out  becoming  more  serious.  In  other  cases  the  paroxysms  gradually 
increase  in  frequency  and  severity.  The  dyspnrea  in  the  attack  is  such 
that  the  features  are  livid,  the  head  forcibly  retracted,  and  death  seems 
imminent  from  apnoea.  In  these  severe  paroxysms  respiration  often 
ceases  entirely  for  a  moment.  When  the  spasm  ends,  a  deep  stridulous 
inspiration  occurs,  after  Avhich  the  breathing  is  natural.  I  have  stated 
also  that  internal  convulsions  are  often  associated  Avith  those,  usually 
tonic,  but  sometimes  clonic,  of  the  external  muscles.  In  the  tonic 
form,  the  thumbs  are  flexed  across  the  palms  of  the  hands,  and  some- 
times are  grasped  by  the  fingers ;  the  great  toes  are  adducted,  and  the 
other  toes  flexed.  In  severe  cases,  the  hands,  forearms,  feet,  and  legs 
are  also  somewhat  flexed  and  rigid.  At  first,  the  contraction  of  the 
external  muscles  is  temporary,  either  corresponding  Avith  the  internal 
spasm,  or  it  is  most  intense  at  the  time  of  the  sj)asm,  though  com- 
mencing .sooner  and  subsiding  later.  After  a  Avhile,  hoAvever,  if  the 
<lisease  continue,  the  spasmodic  action  of  the  external  muscles  becomes 
more  persistent.  In  severe  cases,  nearly  every  inspiration  is  accompa- 
nied by  the  Avheezing  sound,  and  the  paroxysms  of  dyspnuea  are  excited 


508  IN'TERXAL    CONVULSIOXS. 

by  trifling  causes.  Anything  that  suddenly  disturbs  the  mind  or  body 
may  bring  on  the  attack,  as  anger,  tlie  impression  of  cohl,  or  currents 
of  air.  Dr.  West  calls  attention  to  the  fact  that  an  anasarcous  con- 
dition is  sometimes  ])resent,  accompanied  by  albuminuria. 

If  the  convulsions  affect  other  muscles,  as  the  diaphiagm  or  tlie  pec- 
toral and  abdominal  muscles,  which  are  concerned  in  the  respiratory 
function,  Avhile  those  of  the  lar^-iix  escape,  respiration  is  irregular,  or 
even  suspended  for  a  moment,  but  the  stridulous  laryngeal  sound  is 
absent,  as  there  is  no  obstacle  in  the  larynx  to  the  entrance  of  air.  In 
this  form  of  the  disease,  the  infra-mammary  region  may  be  strongly 
retracted  during  the  paroxysm  fi-om  tonic  contraction  of  the  diaphragm. 
In  severe  paroxysms,  whether  the  spasm  be  laryngeal  or  diaphragmatic, 
consciousness  is  neai'ly  or  quite  lost,  the  features  may  be  pallid,  or,  if 
respiration  be  suspended,  may  be  more  or  less  livid.  Relaxation  of  the 
S]ihincters  of  the  bowels  and  bladder,  with  involuntary  evacuations, 
often  occurs  in  this  disease  during  the  attack. 

The  duration  of  the  paroxysm  may  be  a  quarter,  a  half,  or  even  a 
whole  minute.  Total  suspension  of  respiration  for  even  half  a'  minute 
involves  danger.  In  mild  cases  there  may  be  but  few  paroxysms,  and 
they  slight.  In  other  instances  they  occur  in  a  severe  form,  almost 
daily  for  several  weeks  or  even  months.  In  the  following  case  the  mus- 
cles of  the  larynx  were  apparently  not  involved.  The  patient  was 
scrofulous,  and  has  since  had  scrofulous  })eriostitis,  Avith  necrosis  and 
exfoliation  of  the  surfice  of  the  til)ia.  At  the  time  of  the  internal 
convulsions  she  had,  as  seen  by  the  history,  a  scorbutic  or  hemorrhagic 
cachexia. 

Case. — On  the  28th  of  August,  1858,  a  German  female  infimt,  fourteen 
months  old,  nursing,  and  having  eight  teeth,  was  suddenly  seized  with 
clonic  convulsions.  Uniformly  delicate  and  pallid,  she  had  been  in  her 
usual  health  till  the  age  of  twelve  months,  when  she  had  a  single  convul- 
sive attack,  and  from  that  date  had  remained  well  till  August  27th,  when, 
without  any  premonitory  symptom,  she  had  a  stool  consisting  of  almost 
pure  blood,  black  and  offensive.  On  the  morning  of  the  28th  a  similar 
evacuation  occurred,  and  another  in  the  afternoon  immediately  preceding 
the  convulsion.  Pulse  128,  after  the  convulsion  ;  surface  cool  and  j)alli(l; 
flesh  soft,  but  no  emaciation.  Turpentine  was  prescribed  in  two  drop 
doses  every  two  hours,  and  laudanum  in  one  and  a  half  drop  doses,  re- 
peated sufficiently  often  to  insure  quietude. 

On  the  2I)th  the  pulse  was  152.  At  1  r.  m.  she  had  a  general  convul- 
sion, lasting  about  five  minutes;  in  the  evening  she  had  an  evacuation 
similar  to  those  passed  on  the  preceding  day.  The  record  for  August  30th 
states:  "Pulse  from  150  to  160  ;  up  to  this  time  has  been  playful,  but  is 
now  drowsy,  and,  when  disturbed,  fretful ;  manifests  no  desire  for  solid 
food,  as  before  her  sickness,  but  still  nurses;  has  taken  up  to  this  time 
thirty-two  drops  of  turpentine.  "When  she  cries  or  frets,  she  has  a  spas- 
modic attack."  This  was  the  commencement  of  internal  convulsions,  with 
which  this  cliild  was  affected  for  several  months.  An  opportunity  was 
afforded  of  observint;  their  character,  for  her  excitement,  when  she  was 
examined,  was  usually  sufficient  to  produce  them.  After  a  succe.ssiim  of 
short  expirations,  respiration  ceased ;  for  a  moment  she  was  apparently 


PROGNOSIS.  509 

insensible;  eyes  closed;  face  pallid;  no  frothing  at  the  mouth.  The 
return  of  consciousness  and  respiration  was  without  any  laryngeal  rale  ; 
and  after  the  attack  she  seemed  as  well  as  before.  No  external  convul- 
sion and  no  evacuation  of  blood  occurred  after  August  olst. 

There  was  gradual  improvement  in  her  health,  but  she  continued  for 
manv  months  pallid  and  irrital)le,  and  subject  to  attacks  of  internal  con- 
vulsions. On  the  11th  of  April,  l'S.39,  when  twenty-two  months  old,  she 
had  another  attack  of  general  convulsions.  The  record  made  on  that  day 
is:  "  Has  had  internal  convulsions  (one  or  more  paroxysms)  almost  every 
day  since  last  August,  brought  on  usually  by  crying,  when  she  is  corrected 
in  any  wav,  or  her  wishes  are  refused."  Again,  on  Decendier  1,  1859,  it 
is  stated:  "Has  grown  considerably  since  the  last  record,  and  appears  to 
have  recovered,  except  that  at  long  intervals  the  spasms  still  occur." 
She  took  a  preparation  of  iron,  but  her  recovery  seemed  to  be  due  more 
to  the  growth  and  development  of  the  body  and  to  hygienic  thaji  thera- 
peutic measures. 

The  general  health  in  internal  convulsions  is  more  or  less  impaired, 
except  in  mild  forms  of  the  disease,  in  which  the  convulsive  attacks 
soon  cease.  Pallor,  or  a  sickly  and  cachectic  aspect,  irregular,  usually 
constipated  bowels,  poor  appetite,  and  moroseness  or  irritability  of 
temper,  are  common  symptoms  of  severe  and  protracted  cases. 

Diagnosis. — This  disease  is  easily  diagnosticated,  unless  when  its 
symptoms  arc  masked  by  those  of  external  convulsions ;  it  may  then 
escape  notice.  Spasm  of  the  glottis  may  be  mistaken  for  spasmodic 
larynf^itis,  and  vice  versa.  In  some  of  the  published  cases  this  mistake 
appears  to  have  been  made.  Spasmodic  laryngitis  is,  however,  so  dif- 
ferent, not  only  in  its  nature,  but  in  its  clinical  history,  that  a  difteren- 
tial  diagnosis  is  not  diflEicult.  It  is  an  inflammatory  disease,  and  is 
attended  with  febrile  reaction  and  a  sonorous  cough ;  it  commences  at 
night  after  the  first  sleep,  and  from  exposure  to  cold — particulars  in 
regard  to  which  it  contrasts  Avith  true  spasm  of  the  glottis,  which  in 
complicated  cases  is  not  attended  by  any  febrile  symptoms. 

Prognosis — Modes  of  Death. — Statistics  show  great  mortality  in 
this  disease.  Dr.  Reid,  in  a  monograph  on  "Infantile  Laryngismus," 
states  that  of  289  cases  wliich  ho  collated,  115  died.  Rilliet  and  Bar- 
thez  met  Avith  one  favorable  case  in  nine  unfavorable ;  and  Ilerard, 
one  in  seven.  If  the  paroxysms  be  mild,  infrequent,  and  dependent  on 
a  cause  which  can  be  easily  removed,  recovery  is  probable  with  proper 
treatment.  The  cause  may,  however,  be  such,  even  when  the  spasm  is 
mild,  that  the  case  is  necessarily  unfavorable :  as  when  it  is  due  to  dis- 
ease of  the  cerebro-spinal  axis.  AVe  should  not,  hoAvcver,  in  any  case 
consider  the  patient  entirely  safe,  since  grave  symptoms  may  suddenly 
arise,  so  as  to  change  entirely  the  prognosis.  Long  and  severe  par- 
oxysms, with  lividity  of  face,  and  symptoms  of  suffocation,  indicate  an 
unfavorable  result.  The  same  should  be  predicted  also  if  the  infant 
gradually  waste  away,  losing  appetite  and  strength,  especially  if  the  face 
be  ))al]id  and  the  pulse  feeble. 

There  are  three  modes  of  death  in  internal  convulsions.  The  first  is 
•apncca.  The  infant  dies  suffocated  in  the  attack.  Respiration  is  first 
arrested,  and  then  the  pulse  ceases,  and  at  the  autopsy  the  lungs  and 


510  INTERNAL    CONVULSIONS. 

the  cavities  of  the  heart  are  found  engorged  with  dark  blood.  Death 
may  also  result  from  the  state  of  the  brain.  In  such  cases,  passive  con- 
gestion of  the  brain  occurs  from  obstruction  to  the  return  of  blood  from 
this  organ  to  the  heart  and  lungs;  and  if  this  congestion  be  not  soon 
relieved,  serous  effusion  also  occurs.  Death  results  from  the  congestion, 
and  consequent  oedema  or  dropsy. 

The  third  mode  of  death  is  from  exhaustion.  Repeated  and  severe 
attacks  undermine  tiie  constitution;  the  infant  gradually  grows  pallid  and 
thin,  and  dies  of  inanition,  or  of  some  disease  which  this  state  induces. 

TreaTiMEXT. — The  treatment  of  internal  convulsions  has  varied  ac- 
cording to  the  theories  wdiich  physicians  have  held  in  reference  to  its 
cause.  Glandular  enlargement  is  no  longer  regarded  as  a  common 
cause,  and  therefore  treatment  directed  to  its  removal  is  less  frequently 
prescribed  than  formerly.  The  causes  of  internal  convulsions  are  in  part 
very  similar  to  those  of  eclampsia,  and  tlie  remedies  employed  in  the  one 
affection  are,  in  a  measure,  appropriate  in  the  other.  That  dentition  is 
sometimes  a  cause,  is  usually  admitted ;  and  two  cases,  one  of  which 
occurred  in  my  practice,  and  the  other  was  reported  to  me,  appeared  to 
show  that  it  may  have  a  causative  relation.  The  effect  of  dentition  is 
especially  observed  in  weakly  infmts,  when  several  dental  follicles  are 
undergoing  active  evolution.  Thus,  in  one  of  the  cases  to  which  I  refer, 
five  teeth  pierced  the  gums  in  tlie  course  of  two  weeks ;  after  which  no 
convulsive  attack  occurred.  If,  therefore,  the  gums  are  swollen,  the 
propriety  of  scarification  should  be  considered,  especially  if  the  convul- 
sions be  so  severe  as  to  endanger  life. 

In  all  cases  of  internal  convulsions  a  careful  examination  should  be 
made,  in  order  to  detect  any  aberration  from  the  normal  state  which 
might  cause  nervous  excitation.  The  condition  of  the  digestive  organs 
should  be  ascertained,  and  evacuants  or  other  remedies  prescribed  if 
there  be  evidence  of  their  derangement. 

Sometimes  the  alimentation  of  the  infant  is  at  fault.  It  is,  perhaps, 
bottle-fed,  and  the  stools  have  an  unhealthy  appearance.  Attention 
should  be  given  to  the  preparation  of  its  food  and  the  times  of  its  feed- 
ing ;  or,  if  it  nurse,  the  mother  or  wet-nurse  who  suckles  it,  should  have 
plain  but  nutritious  diet,  live  with  regularity,  and  give  the  breast  to  the 
infant  at  regular  intervals.  If  there  be  a  torpid  state  of  the  intestines, 
Dr.  Meigs  recommends  ''castor  oil  and  aromatic  syrup  of  rhubarb 
rubbed  up  together,  three  parts  of  the  former  and  five  of  the  latter." 
A  simple  enema  answers  well  in  such  cases,  and,  in  debilitated  infiints, 
this  is  preferable  to  medicine  administered  by  the  mouth.  If  diarrhoea 
be  present,  and  it  persist  after  the  requisite  changes  are  made  in  regard 
to  the  diet,  remedies  calculated  to  relieve  it,  which  are  mentioned  else- 
where, should  be  employed.  Marshall  Ilall  states  that  he  has  ordinarily 
succeeded  in  cuiing  the  disease  by  attending  to  the  condition  of  the  gums 
and  digestive  organs. 

Since  rachitis  is  a  not  uncommon  cause,  the  child  should  ])e  examined 
in  reference  to  the  rachitic  manifestations,  and  if  they  appear  the  treat- 
ment appropriate  for  rachitis  is  required. 

In  pallid  and  cachectic  infants,  tonics  are  indicated.  The  elixir  of 
Calisaya  bark  with  iron  in  half-teaspoonful  doses,  three  or  four  times 


TREATMENT.  511 

daily,  to  an  infant  of  one  year,  is  an  eligible  preparation.  The  com- 
pound tincture  of  bark,  or  of  gentian,  or  t!ie  two  mixed,  may  be  given 
instead  of  the  Calisaya  bark.  The  preparations  of  iron  are  frequently 
to  be  preferred  to  the  vegetable  tonics,  as  the  citrate  of  iron  and  bismuth, 
citrate  of  iron  and  quinia,  the  syrup  of  iodide  of  iron,  or  the  Avine  of 
iron.  To  an  infant  of  one  year  the  syrup  may  be  given  in  doses  of 
three  drops,  the  citrates  in  one-grain  doses,  and  the  wine  in  doses  of 
one  teaspoonful,  every  four  hours.  If  the  child  be  old  enough,  it  may 
take  iron  in  lozenges,  as  those  of  chocolate  and  iron. 

Antispasmodics,  as  asafetida,  valerian,  and  oxide  of  zinc,  are  often 
prescribed  in  this  malady,  but  they  are  less  efficacious  than  the  general 
tonic  measures  -which  I  have  indicated.  The  salutary  effect  of  bromide 
of  potassium  in  eclampsia  and  epilepsy  certainly  justifies  the  trial  of 
this  awent  in  internal  convulsions,  if  they  persist  after  the  employment 
of  invigorating  measures. 

Hygienic  measures  are  of  the  utmost  importance.  The  infant  should 
reside  in  dry  and  airy  apartments,  and  should  be  kept  much  of  the  time 
through  the  day  in  the  open  air.  Remarkable  success  sometimes  attends 
this  simple  expedient,  when  medicines  have  entirely  ftiiled.  Mr. 
Robertson,^  of  Manchester,  relates  five  severe  cases  in  which  this  malady 
was  cured  by  exposure  of  the  infants  several  hours  daily  to  a  cool  atmos- 
phere. These  cases  were  treated  in  the  winter  months,  and  were  kept 
outdoor,  even  during  strong  winds.  Mr.  Robertson  has  records  of 
forty  cases,  all  occurring  between  Deceml)er  and  April,  while  he  has 
seen  no  case  in  the  summer  months.  As  the^  result  of  such  extensive 
experience,  this  writer  recommends  "  the  free  exposure  of  the  infant  out 
of  doors,  for  many  hours  daily,  to  a  dry,  cold  atmosphere,  and  if  the  air 
be  dry,  the  colder  the  better."  Dr.  Marshall  Hall's  experience  was 
similar.  Says  he :  "  The  curative  influence  of  the  air.  and  especially 
of  the  sea-breezes,  is  not  less  marked  in  this  affection  than  in  hooping- 
cough."  Mr.  Robertson  recommends  also,  as  part  of  the  tonic  treat- 
ment, "free  s;)onging  of  the  body  every  morning  with  cold  water."  In 
February,  1867,  I  attended  a  nursing  infant,  five  months  old,  with  in- 
ternal convulsions,  the  paroxysms  being  attenderl  with  lividity  of  the 
face,  and,  at  times,  tonic  convulsions  of  the  limbs.  xVmong  the  reme- 
dies employed  was  bromide  of  potassium,  but  more  benefit  obviously 
accrued  fi-ora  keeping  the  infant  much  of  the  time  in  the  open  air,  than 
from  the  medicines  employed.  The  disease  passed  off  in  six  or  eight 
weeks. 

Unless  the  cause  be  of  such  nature  that  it  cannot  be  removed,  the 
above  hygienic  and  therapeutic  measures  Avill,  in  a  large  proportion  of 
ca.ses,  be  followed  by  a  satisfactory  result. 

The  mother  or  nurse  may  abridge  the  paroxysm  by  raising  the  infant, 
blowing  upon  it,  sprinkling  water  in  the  face,  or  gently  stroking  it. 
Dr.  Hall  recommends  tickling  the  nostrils  with  a  feather,  to  produce 
respiration,  or  the  fauces,  to  occasion  vomiting,  and  thereby  interrupt 
the  paroxysm.  Anything  which  produces  a  sudden  and  profound  effect 
upon  the  system  may  abridge  the  attack.     This  was  effected  in  one  case, 

1  London  Med.  Gazette,  Jan.  14,  18G5. 


512  CHOREA. 

in  the  practice  of  Di*.  C.  D.  Meigs,  by  applying  a  cloth  wrapped  around 
ice  over  the  epigastrium  and  the  lower  part  of  the  sternum.  The  chief 
(lander  during  the  attack  is  from  congestion  of  the  brain,  with  effusion 
of  serum  or  extravasation  of  blood.  If  the  attack  be  severe,  and  the 
features  coagested,  so  that  there  is  evident  danger  of  such  a  result,  cold 
applications  should  be  made  to  the  head,  derivatives  used  for  the  ex- 
tremities— as  sinapisms,  or  mustard  foot-baths — and  the  bowels  should 
be  speedily  opened  by  encmata. 


CHAPTER  XIY. 

CHOKEA. 

Chorea,  or  St.  Vitus's  or  St.  Guy's  dance,  is  a  neurosis,  which  is 
characterized  by  irregular  and  involuntary  muscular  movements,  with- 
out loss  of  consciousness.  The  movements  occur  in  the  muscles  of  voli- 
tion, and  there  is  probably  no  one  of  them  that  may  not  be  engaged, 
thouo-li  some  are  more  frequently  affected  than  others.  It  is  not  known 
that  any  involuntary  muscle  is  ever  involved,  though  Sir  William  Jen- 
ncr  has  expressed  the  opinion  that  occasionally  the  papillary  muscles  of 
the  heart  are,  so  that,  by  their  spasmodic  contractions,  they  produce  in- 
sufficiency of  the  mitral  valve.  This,  according  to  him,  affords  expla- 
nation of  the  fact  that,  in  certain  instances,  a  mitral  regurgitant  murmur 
is  heard,  which  disappears  about  the  time  that  the  external  movements 
cease.  It  is  rare,  however,  that  a  mitral  regurgitant  murmur,  heard 
during  chorea,  ceases  when  the  latter  terminates,  and  it  is  not  improb- 
able that  in  such  cases  there  is,  after  all,  a  lesion  of  the  valve,  due  to 
recent  endocarditis,  whether  of  a  rheumatic  or  other  origin.  For  a 
valve  may  be  so  thickened  by  recent  inflammation  as  to  cause  a  murmur, 
and  after  a  few  weeks  or  months  the  infiltrating  substance  be  so  ab- 
sorbed that  the  murmur  is  no  longer  audible.  If  we  admit  the  fiict  that 
cardiac  bruits  occasionally  appear  and  disappear  with  chorea,  this  ex- 
planation seems  to  me  more  plausible  than  that  of  Jenner.  Ilillier 
says,  in  reference  to  this  subject:  "  My  own  experience  leads  mo  to 
doubt  the  existence  of  dynamic  apex  murmurs  in  chorea,  that  is  to  say, 
murmurs  produced  in  hearts  entirely  free  from  organic  change.  If  such 
murmurs  ever  occur,  they  are  certainly  rare.  Organic  murmurs  of  the 
heart,  on  the  other  hand,  are  common  in  chorea,  and  I  am  inclined  to 
believe  that  organic  disease  of  the  heart  often  exists  in  chorea  when 
there  is  no  murmur."  We  shall  sec  that  this  opinion  is  correct,  by  a 
case  presently  to  be  related.  Ilillier  also  calls  attention  to  the  fact  that 
choreic  movements  are  irregular;  but  a  cardiac  bruit  occurring  regularly 
and  uniformly,  if  not  due  to  organic  disease,  would  require  rhythmical 


CAUSES.  513 

contractions  of  the  papillarj  muscles  to  produce  it.  We  infer  from  this 
that  the  bruit  does  not  have  a  choreic  origin. 

In  the  class  of  children's  diseases  in  the  Bureau  for  the  Relief  of  the 
Outdoor  Poor  in  New  York  City,  16,9SG  children  were  treated  in  the 
two  years  and  three  months  ending  with  March  31,  1877.  Of  these 
cases  82,  or  one  in  every  207,  had  chorea.  The  patients  were  all  under 
the  age  of  fifteen  years.  Statistics  published  by  observers  in  Europe 
show  that  the  relative  frequency  of  this  disease  is  probably  about  the 
same  in  the  large  European  cities  as  in  New  York.  Thus,  according  to 
Ilillior,  amongst  122,021  out-patients  treated  at  the  Hospital  for  Sick 
Children,  in  London,  406,  or  1  in  322,  had  chorea;  Avhile  of  the  in-pa- 
tients 174  in  5585,  or  1  in  every  32,  were  choreic.  In  the  Parisian 
Hospital  for  Sick  Children,  of  84,968  admitted  in  twenty-one  years,  531 
had  chorea,  or  1  in  every  161. 

AiJE. — Chorea  may  occur  at  any  period  of  life,  but  a  large  majority 
of  the  cases  are  in  childhood.  It  is  rare  in  infancy,  and  it  rarely  begms 
after  pubert}'.  Under  the  age  of  five  years  the  proportionate  number 
diminishes,  as  we  approach  the  time  of  birth.  Tlie  youngest  in  the  sta- 
tistics of  Hillier  was  three  months.  In  1870,  in  the  Bureau  for  the 
Outdoor  Poor  a  child  was  presented  for  treatment,  Avho  the  mother  said 
had  had  chorea  from  birth,  and  in  1877  I  treated  a  young  woman  with 
severe  general  chorea,  Avho,  repeatedly  questioned,  uniformly  said  that 
she  had  had  the  disease,  without  any  assignable  cause,  from  the  first 
week  of  her  life,  and  her  friends  corroborated  the  statement.  The  fol- 
lowing table  exhibits  the  relative  frequency  of  chorea  at  different  ao-es: 

6  years  0  to  10  10  to  15 

and  under.  years.  yeurs. 
Children's  Hospital,  London,  Hillier,  none  over  12  years 

admitted '       .       81  237  104 

M.  RutV. 10  61  118 

Bureau  for  Outdoor  Poor  (prior  to  1875)            ...         2  26  16 

At  and  under     3  to  5  5  to  10  10  to  15 

3  years.         years.  years.  years. 

Bureau  for  Outdoor  Poor  (since  January  1,  1875)      5  30  237  J30 

M.  See  collected  the  statistics  of  531  cases  occurring  in  the  Chil- 
dren's Hospital,  Paris,  and  from  them  concludes  that  the  ma.ximum 
frequency  of  chorea  is  between  the  si.xth  and  tenth  years.  Only  twenty- 
eight  of  his  cases  were  under  six  years,  the  remainder,  503,  occurring 
between  the  sixth  year  and  puberty. 

Causes. — The  profession  arc  nearly  agreed  in  regard  to  certain 
causes  of  chorea,  while  there  is  a  diversity  of  opinion  in  reference  to 
others.  It  is  a<lmitted  that  in  a  large  proportion  of  cases  there  is  a 
neuropathic  state,  which  antedates  and  predisposes  to  chorea.  Thi.^ 
state  is  often  manifested  in  the  family  history  by  a  proneness  to  affec- 
tions of  tlie  nervous  system,  and  in  the  individual  by  a  highly  excitabjp 
state  of  the  emotions,  so  that  lie  evinces  joy,  grief,  or  anger,  from 
slight  causes. 

All  writers  admit  that  there  is  often  an  inherited  predisposition  to 
chorea.  In  27  of  48  cases,  Iladcliffe  found  that  father,  mother,  liroMier, 
or  sister  liad  been  or  was  the  subject  of  one  or  other  of  the   f^lb^wing 

83 


514  CHOREA. 

disorders :  panalysis,  epileps}^  apoplexy,  hysteria,  or  insanity.  The 
chil(h-cn  of  parents  who  when  young  had  chorea,  or  Avho  exhibit  prone- 
ness  to  aihueuts  of  the  nervous  system,  are  more  liable  to  chorea  than 
other  children.  Hence  the  fact  sometimes  observed,  of  different  chil- 
dren in  the  same  family  becoming  affected  with  chorea  when  they  attain 
the  age  at  Avhich  this  disease  ordinarily  occurs.  In  one  family  in  my 
practice,  three  girls  at  different  times  Avere  affected. 

Se.x. — The  emotions  are  strong  in  girls,  since  in  them  the  nervous 
system  predominates,  while  the  muscular  power  is  weaker  than  in  boys. 
Hence  a  partial  explanation  of  the  fact  which  statistics  fully  establish, 
that  the  proportion  of  choreic  boys  to  girls  is  about  in  the  ratio  of  one 
to  two  and  a  fraction.  I  have  remarked,  in  this  city,  tlie  large  propor- 
tion of  cases  in  school-girls  between  the  ages  of  six  and  twelve  years; 
the  severe  discipline  and  confinement  of  the  public  schools  no  doubt 
increasinfT  the  strength  of  the  emotions,  and  weakenino-  the  control  of 
the  will  over  the  muscles. 

Pi'oportion  of  Males  to  Females. 

27  to  73.  Hiic:hes's  Digest  of  Cases  in  Guy's  Hospital,  1846. 

138  to  893.  M.  See. 

50  to  94.  Outdoor  Department,  Bellevue. 

276  to  490.  Cliildren's  Hospital,  London  West  (Lumleian  Lectures). 

491  to  10-39  =  1  to  2.1.5. 

The  cases  treated  in  the  Outdoor  Department,  Bellevue,  since  those 
contained  in  the  above  table  occurred,  give  a  larger  percentage  of  females. 
Between  April,  1878,  and  December,  1883,  288  choreic  cases  were 
treated  in  this  department,  and  of  these  the  proportion  of  boys  to  girls 
was  1  to  2.4.      (Olinpin.) 

Uterine  Irritatiux. — The  peculiar  changes  occui'ring  in  the  female 
at  puberty  constitute  an  important  cause.  Hence  another  reason  of  the 
excess  of  female  cases.  Dysmenorrhoea  and  pregnancy  are  causes  of  a 
large  proportion  of  cases  in  the  first  years  of  puberty.  In  the  male,  on 
the  other  hand,  the  changes  of  puberty  do  not  appear  to  increase  the 
liability  to  the  disease,  directly  or  indirectly,  and  male  cases,  after  the 
age  of  twelve  years,  are  comparatively  rare.  Radcliffe'  states  that  after 
the  ninth  year,  females  are  more  liable  to  chorea  than  males,  in  the 
proportion  of  5  to  2 ;  while  before  the  ninth  year,  the  two  sexes  are 
equally  liable  to  it.  Carefully  prepared  statistics,  however,  notwith- 
standing the  high  authority  of  Radcliffe,  show  a  preponderance  of  girls 
under  the  age  of  nine  years,  though  not  so  great  as  over  that  age.  In 
the  Outdoor  Department  at  Bellevue,  of  35  patients  under  the  age  of 
ten  years,  22  were  girls,  while  of  20  from  the  age  of  ten  years  to  six- 
teen 15  were  girls. 

According  to  West,^  in  775  children  with  chorea,  under  the  ago  of 
ten  years,  treated  in  the  London  Children's  Hospital,  61  per  cent. 
were  girls. 

ANjEMIA. — Among  the  most  common  predisposing  causes  of  chorea 
is  anaemia.     It  is  present  in  so  large  a  proportion  of  cases,  exhibiting 

1  Reynolds's  System  of  Medicine.  '  Lumleian  Lectures. 


CAUSES.  515 

itself  by  pallor  of  the  countenance  and  other  characteristic  signs,  that 
medicines  designed  to  improve  the  quality  of  the  blood  are  among  the 
most  valued  remedies.  The  peculiar  neuropathic  state  already  alluded 
to,  which  needs  only  a  slight  additional  cause  for  the  development  of 
chorea,. is,  no  doubt,  lai-gely  dependent  on  impoverishment  of  the  blood, 
if  it  be  not  sometimes  due  entirely  to  it.  Among  the  poor  of  a  large 
city  like  New  York,  or  in  hospital  practice,  the  proportion  of  anaemic 
cases  of  chorea  is,  for  obvious  reasons,  much  larger  than  would  appear 
from  the  general  statistics. 

Rheumatism. — Dr.  Copsland,  M.  Bouteille,  and  afterward  M.  Ger- 
main See,  in  a  more  extended  monograph,  directed  the  attention  of 
the  profession  to  rheumatism  as  a  cause  of  chorea.  Subsequent  obser- 
vations have  established  the  fact  that  rheumatism,  or  the  rheumatic 
diathesis,  is  so  frequently  present  that  it  obviously  sustains  an  important 
relation  to  chorea,  though  in  what  matter  is  not  fully  ascertained.  This 
relation  between  the  two  is  more  frequently  observed  in  some  countries 
than  in  others.  In  England  and  France,  so  large  a  proportion  of 
choreic  patients  present  a  history  of  rheumatism  either  in  themselve*' 
or  family,  that  certain  physicians  of  these  countries  belie*'e  that  rhe" . 
matism  is  the  most  common  cause  of  the  disease.  In  Germany,  on  the 
other  hand,  according  to  Romberg,  in  the  majority  of  cases  no  relation 
can  be  traced  between  chorea  and  rheumatism.  Probably  the  largest 
number  of  choreic  cases  treated  in  one  institution  in  this  country  is  in 
the  Bureau  for  the  Relief  of  the  Outdoor  Poor,  in  this  city ;  and  it  has 
been  our  practice  during  the  last  few  years  to  eocamine  each  patient  for 
heart  disease,  and  question  the  parents  as  regards  rheumatism.  With- 
out referring  to  the  exact  statistics,  I  should  say  that  more  than  half 
gave  the  history  of  rheumatism  in  themselves  or  parents,  or  had  un- 
ef^uivocal  signs  of  heart  disease.  One  of  the  physicians  of  the  class 
found  that  22  in  38  consecutive  cases  of  chorea  gave  the  history  of 
rheumatism  or  of  heart  disease  in  themselves  or  parents. 

Various  theories  have  been  promulgated  in  explanation  of  the  rela- 
tionship of  the  rheumatic  and  choreic  diseases.  It  has  been  suggested 
that  chorea  is  due  to  rheumatism  of  the  brain  or  spinal  cord.  This  is 
simply  an  hypothesis,  the  truth  or  falsity  of  which  can  only  be  ascer- 
tained by  carefully  conducted  necropsies ;  but  the  theory  appears  im- 
probable in  view  of  all  the  facts.  Another  theory  attributes  chorea  to 
the  state  of  the  l>lood  which  is  present  in  those  having  rheumatism  or 
the  rheumatic  diathesis,  as  well  as  in  certain  other  conditions.  This 
theory  is  enunciated  by  Dr.  Ogle,  as  follows :  "  Recognizing  the  fre- 
quent existence  of  these  fibrinous  deposits  or  granulations  on  the  heart's 
valves  in  chorea,  I  should  be  much  inclined  to  look  u[)on  these  post- 
mortem appearances  rather  as  results  of  some  antecedent  general  condi- 
tion of  the  blood,  common  also  to  the  choreic  condition.  It  is  very 
freely  recognized  that  this  affection  is  frequently,  in  some  way  or  other, 
connected  with  that  condition  of  blood  which  obtains  in  what  we  call 
an.cmia,  or  that  existing  in  rheumatic  constitutions.  In  both  of  these 
states  we  know  that  the  fibrin  of  the  blood  is  much  in  excess  (as  also  it  is 
in  ))regnancy,  another  condition  looked  u])on  as  obnoxious  to  cliorea): 
and  in  these  states  we  know  that  the  fibrin  with  which  the  blood  is  sur- 


516  CHOREA, 

charged  is  veiy  prone  to  be  readily  precipitated,  either  owing  to  its 
superabundance,  or  from  other  obscure  and  acquired  properties  . 
upon  the  heart's  walls  or  valves.  May  not  this  hyperinosis  be  the  ex- 
planation of  the  coincidence  alluded  to?"^ — namely,  the  occurrence  of 
citorea  in  those  affected  with  rheumatism.  Others  still  hold  that  chorea 
is  the  result  of  the  heart  disease,  and  not  directly  of  rheumatism,  occur- 
ring Avhen  the  heart  is  affected  from  other  causes,  as  well  as  when  the 
lesion  has  a  rheumatic  origin.  This  theory  is  plausible,  and  probably  to 
a  certain  extent  correct.  Heart  lesions,  observed  in  children,  result  from 
scarlet  fever  in  a  considerable  proportion  of  cases,  though  it  is  true  that 
the  endocarditis  and  pericarditis  of  scarlet  fever  are  believed  often  to 
have  a  rheumatic  origin,  occurring,  in  some  instances,  from  scarlatinous 
rheumatism,  but  in  other  cases  from  scarlatinous  uraemia.  Occasionally, 
also,  the  heart  disease  appears  to  have  occurred  independently  of  both 
rheumatism  and  scarlet  fever.  Thus  in  a  fatal  case  of  chorea  with  val- 
vular disease,  related  to  the  London  Pathological  Society,  April  6, 
18G0,  the  child  was  always  healthy  up  to  the  present  illness  (chorea), 
and  there  was  no  history  of  rheumatism  in  the  ftmily.  The  more  ob- 
servations accumulate,  the  more  important  does  heart  disease  in  itself 
appear  as  a  cause  of  chorea.  In  nearly  all  recorded  cases  of  fatal 
chorea,  which  were  supposed  to  be  due  to  rheumatism,  and  in  which 
post-mortem  examinations  were  made,  endocardial  and  usually  valvular 
disease  has  been  found.  We  shall  see  that  certain  eccentric  causes  of 
irritation  aid  in  producing  chorea,  and  may  not  the  valvular  disease,  or 
the  endocarditis  which  causes  the  valvular  lesion,  operate  in  a  similar 
manner  as  a  cause  'i  We  know  that  in  the  adult  severe  cardiac  disease 
often  profoundly  affects  the  nervous  system,  perhaps  in  consequence  of 
the  irregular  and  embarrassed  circulation ;  and  certainly  in  the  child  a 
similar  cause  would  be  likely  to  produce  a  more  decided  effect. 

But  there  is  an  injienious  theorv  which  attributes  chorea  to  minute 
emboli  detached  from  vegetations  on  the  valves,  and  arrested  by  capil- 
laries in  the  corpora  striata,  or  other  portion  of  the  cerebro-spinal  axis. 
Since  attention  was  directed  to  this  matter,  emboli  have  been  found  in 
one  case  in  the  medulla  oblongata,  although  this  portion  of  the  spinal 
axis  appeared  healthy  to  the  naked  eye.  Further  observations  are 
necessary  in  order  to  determine  how  much  truth  there  is  in  this  theory ; 
but  it  seems  probable,  for  reasons  to  be  stated,  that  if  capillary  embolism 
do  cause  chorea,  it  is  only  in  a  limited  number  of  cases,  and  that  there- 
fore those  British  observers  who  regard  it  as  the  common  cause,  have 
been  led  into  error  by  the  large  ])roportion  of  choreic  cases  which  in 
their  climate  is  complicated  by  valvular  lesions. 

That  embolism  is  not  a  common  cause,  if  indeed  a  cause  at  all,  appears 
probable  from  the  folloAving  facts :  First.  In  many  cases  of  chorea  there 
are  no  vegetations,  or  other  appreciable  lesions,  which  could  give  rise  to 
emboli.  Secondly.  Most  patients  recover,  and  some  speedily,  by  treat- 
ment, which  we  woidd  not  expect  if  the  cause  were  embolism.  Thirdly. 
Embolism  is  not  infrequent  in  the  cerebral  vessels  of  the  adult,  without 
the  occurrence  of  chorea.     Indeed,  the  conditions  which  produce  embo- 

*  British  and  Foreign  Med.-Chir.  Rev..  January,  1808. 


CAUSES.  517 

lism  are  much  more  common  in  adults  than  in  chihlren,  while  the  reverse 
is  true  as  regards  the  liability  to  chorea.  Fourthly.  Dogs  sometimes 
have  chorea,  but  the  injection  of  minutely  divided  fibrin  or  other  sub- 
stance into  the  veins  of  the  dog  is  not  folloAved  by  chorea  as  one  of  the 
phenomena.  Fifthly.  AVere  capillary  emboli  the  cause,  we  would  ex- 
pect to  find  an  occasional  embolus  in  the  larger  vessels  of  the  brain,  so 
as  to  be  appreciable  to  the  naked  eye  ;  but  I  find  no  examples  of  this 
in  all  the  recorded  autopsies  which  I  have  been  able  to  consult.  More- 
over, it  seems  improbable  that  capillary  embolism,  when  producing  no 
lesion  appreciable  to  the  naked  eye,  would  so  arrest  the  circulation,  and 
disturb  the  function  of  the  brain  or  spinal  cord,  as  to  cause  chorea,  for 
the  ill-effects  of  such  an  obstruction  would  be  likely  to  be  obviated  by 
the  numerous  anastomoses. 

In  1877  the  unusual  opportunity  occurred,  in  my  asylum  practice,  of 
determining  whether  there  are  any  fixed  anatomical  characters  in  the 
cerebrospinal  axis  in  chorea ;  in  other  words,  whether  chorea  is  a  neu- 
rosis, as  we  have  designated  it  in  our  definition,  and  the  case  is  so  inter- 
esting in  other  respects  that  I  shall  relate  it  entire. 

Case. — Charles,  a  foundling,  born  Oct.  15,  1874,  was  received  in  the 
New  York  Foundling  Asylum  soon  after  his  birth.  When  two  weeks  old 
he  was  removed  to  a  family  in  the  city  to  he  wet-nursed.  His  health  con- 
tinued good  till  the  age  of  tlu-ee  months,  when  he  had  bronchilis  and  kera- 
titis, the  former  mild,  and  lasting  only  a  few  days,  but  the  latter  continu- 
ing nearly  two  months,  l)eing  attended  by  moderate  injection  of  the  con- 
junctiva, with  some  purulent  discharge,  which  caused  adhesion  of  the 
eyelids  during  sleep.  From  this  time  he  remained  well,  with  the  excep- 
tion of  a  sliglit  attack  of  dysentery,  till  the  age  of  about  nine  and  a  half 
months,  when  he  began  to  have  febrile  symptoms.  In  the  morning  hours 
he  seemed  ui  tolerable  health,  but  at  midday,  or  a  little  later  than  midday, 
of  each  day,  he  was  observed  to  have  slight  irregularity  or  embarra.ssment 
of  respiration,  and  lividity,  with  coolness  of  the  extremities,  which  state, 
sappo-ed  at  the  tim3  to  be  the  algid  stage  of  a  somewhat  irregular  inter- 
mittent fever,  lasted  from  one  to  two  or  three  liours,  an<l  was  succeeded 
by  febrile  movement,  which  continued  during  the  reuuiinder  of  the  day; 
sometimes  the  fever  abated  in  perspiration. 

On  August  4,  1875,  a  few  days  after  the  commencement  of  these  irreg- 
ular febrile  symptoms,  Charles  was  brought  to  the  dispensary  of  the  insti- 
tution for  treatment,  and  Dr.  Reid,  wh(j  was  on  duty  that  day,  carefully 
examined  the  case,  and  prescribed  the  sulphate  of  quinia.  This  medicine 
continued  a  few  days  rvdieved  the  .symptoms,  but  every  four  to  six  weeks, 
for  more  than  a  year,  these  febrile  attacks  returned,  and  were  uniformly 
relieved  i)y  the  same  medicine.  In  other  respects  the  patient  had  the 
usual  health. 

On  or  ab:>ut  February  1, 1878.  the  nurse  noticed  that  Charles  had  what 
she  designated  "spells  of  trendding,"  in  which  he  seemed  excited  and 
feverish,  and  wliich  were  sometiiues  attended  by  or  followed  by  perspira- 
tion. In  the  course  of  another  week  the  irregular  muscular  movements 
became  more  marked  and  constant,  and  they  increa.-^ed  in  severitv  till  lu-ar 
tlie  time  ef  the  admission  of  the  patient  into  the  asylum,  about  March  1st. 
file  nurse  had  noticed  in  Februarv  slowness  and  some  difficidty  of  niietu- 
riti(jn,  and   Dr.  Reid  examined  him  with  a  catheter  for  calculus,  and  alsu 


518  CHOREA. 

his  prepuce  for  any  source  of  irritation,  but  nothing  abnormal  was  dis- 
covered, either  in  the  contlitiou  of  the  bhidder  or  the  external  organs. 
In  the  latter  part  of  April,  the  chorea  had  become  so  severe,  that  irregu- 
lar muscular  action  occurred  in  all  the  limbs,  and  in  the  muscles  of  the 
eyes,  producing  such  grimaces  and  contortions  with  strabismus,  that  the 
woman  with  whom  he  was  boarding  became  alarmed,  and  returned  him 
to  the  asylum,  stating  that  he  had  become  crazy. 

On  March  12th  my  attention  was  first  called  to  this  child,  when  I  made 
the  following  entry  in  my  note-book :  Family  history  unknown;  no 
history  of  rheumatism  in  patient's  case,  he  may  or  may  not  have  had  it; 
heart  sounds  normal;  pulse  104 ;  all  the  limbs  and  the  muscles  of  the 
face,  eyes,  and  eyeliils  involved  in  choreic  movements,  which  continue 
constantly  e.Kcept  during  sleep.  The  patient  cannot  Avalk  or  stand  with- 
out support;  appetite  good,  apparently  better  than  in  health,  for  he  eats 
every  kind  of  food  handed  to  him,  and  carries  the  food  with  his  own  liand 
to  his  mouth,  although  these  movements  are  very  irregular  and  jerking. 
Three  drops  of  Fowler's  solution  ordered  after  each  meal. 

3Iarch  17. — Condition  not  much  changed,  but  perhaps  slight  improve- 
ment ;  in  addition  to  other  choreic  movements  the  eyes  twitch  spasmodic- 
ally ;  })ulse  84;  temperature  98i°;  bowels  regular;  no  cough ;  appetite 
good.     Increase  medicine  to  five  drops. 

SOth. — The  urine  examined  since  the  last  record  was  found  very  pale 
and  abundant;  its  specific  gravity  low,  1040,  without  albumen.  When  an 
equal  (juantity  of  nitric  acid  was  added  to  it,  after  twelve  houi'S  crystals 
of  nitrate  of  urea  occupied  about  one-half  of  the  volume  of  the  urine. 
The  patient's  sleep  is  quiet,  but  the  choi'cic  movements  recommence  as 
soon  as  he  awakens,  but  in  a  milder  form;  is  able  to  walk  without  sup- 
])ort,  but  with  unsteady  gait.  My  term  of  service  ended  March  81st.  On 
the  following  day,  laryngo-tracheitis  was  suddenly  developed,  ending 
fatally  in  forty-eight  hours,  at  the  age  of  two  years  five  and  a  half  months. 

AutopAij,  April  4th.  Slight  oedema  about  the  a]:)erture  of  the  glottis; 
general  and  intense  redness  of  mucous  membrane  of  larynx,  trachea,  and 
bronchial  tubes ;  as  fixr  as  they  can  be  traced,  jxjsterior  portions  of  lungs 
greatly  congested.  The  heart,  lungs,  brain,  Avith  one  eye  attached  to  it 
by  optic  nerve,  and  the  entire  spinal  cord  were  sent  to  Prof.  Francis  Dela- 
field,  for  microscopic  examination.  They  were,  as  soon  as  removed,  placed 
in  a  solution  of  bichromate  of  potassium.  The  following  is  a  brief  state- 
ment of  the  examination,  which  was  made. 

Microscopic  Appearances.  By  Prof  Francis  Delafield.  Brain — 
presented  no  change  apparent  to  the  naked  eye,  except  a  considerable  de- 
gree of  congestion.  It  was  hardened  in  bichromate  of  potassium  and  chro- 
mic acid.  Minute  examination  of  the  convolutions  of  the  brain,  the  large 
ganglia,  the  cerebellum,  the  pons  Varolii,  and  the  medulla  oblongata 
showed  nothing  except  a  uniform  filling  of  the  vessels  Avith  blood,  as  if 
they  were  injected.  There  Avere  no  apoplexies,  no  changes  in  the  walls  of 
the  vessels. 

Spinal  cord — appeared  to  be  entirely  normal. 

Tlie  Heart. — The  auricles  and  ventricles  Avere  of  normal  size.  The 
aortic  valves  were  atheromatous,  and  somewhat  rigid  ;  the  mitral  valves 
Avere  thickened  and  insuflicient ;  the  endocardium  of  the  left  ventricle  was 
thickened. 

The  Lungs. — The  capillaries  in  the  walls  of  the  air-vesicles  Avere  dilated, 
and  there  Avas  an  increase  of  e]Mtheiial  cells  witliin  the  air-vesicles. 

In  this  case  there  seemed  to  be  no  lesion  associated  with  the  chorea  ex- 


CAUSES.  519 

cept  the  organic  disease  of  the  heart,  and  the  changes  in   the  lungs  sec- 
ondary to  this  condition  of  the  heart. 

The  above  microscopic  examination  was  made  witli  sufficient  minute- 
nass,  and  it  is  seen  tliut  no  emboli  were  discovered,  and  no  lesion  of  the 
cerebro-spinal  axis  except  congestion,  which  was  attributable  to  the  mode 
of  death,  namely,  by  obstructed  respiration.  Moreover  it  will  be  recol- 
lected that  there  were  no  cardiac  bruit'<,  and  apparently  not  sufficient 
roughness  of  the  edge  or  surface  of  the  valves  to  cause  precipitation  of 
fibrin,  which  would  be  necessary  in  order  that  emboli  should  form. 

Fright. — A  not  infrequent  exciting  cause  of  chorea  is  sudden  and 
profound  emotion,  especially  fright.  All  statistics  give  fright  as  the 
cause  of  a  certain  proportion  of  cases,  though  there  are  usually  other 
potential  cooperating  causes,  as  angemia  or  valvular  disease.  Fright 
was  stated  as  the  cause  of  chorea  in  31  of  the  100  cases  occurring  in 
Guy's  Hospital,  reported  by  Hughes,  or  nearly  one  in  three.  But  the 
statistics  of  other  observers  do  not  give  so  large  a  pi'oportion  of  cases 
originating  in  this  way.  Chorea  may  commence  within  a  few  hours 
after  the  fright,  or  not  till  the  lapse  of  several  days  (eight  or  ten).  If 
several  weeks  have  passed  since  the  fright,  as  in  some  reported  cases, 
the  chorea  is  probably  du-e  to  other  causes.  In  rare  instances,  chorea 
is  said  to  have  been  caused  by  sudden  and  excessive  joy. 

I.MiTATiox. — Under  unusual  circumstances,  especially  in  a  state  of 
great  mental  excitement,  imitation  has  been  known  to  cause  a  form  of 
chorea.  Hecker  describes  an  epidemic  of  it,  occurring  in  the  middle  ages, 
and  spreading  through  villages.  In  modern  ti'mes  it  is  rare  that  chorea 
originates  from  this  cause,  nevertheless  occasional  examples  have  been 
recorded. 

But  the  disease  which  occurs  from  imitation  differs  from  the  ordinary 
form,  and  has  been  termed  chorea  major ;  Avhile  the  chorea  Avhicli  is  the 
subject  of  this  article  is  sometimes  designated,  in  contradistinction, 
chorea  minor. 

In  chorea  major  the  patient  leaps,  dances,  or  whirls  like  a  top.  It 
has  its  origin  commonly  in  religious  excitement,  and  spreads  by  imita- 
tion almost  in  the  manner  of  an  infectious  disease.  The  epidemic  of 
the  middle  ages  was  a  chorea  major.  I  have  not  been  able  to  find  any 
account  of  cases  spreading  by  imitation,  in  modern  times,  which  were 
not  examples  of  the  same  form  of  chorea.  Thus  in  the  Edin.  Jour, 
of  Med.  and  Surg.,  for  July,  1839,  there  is  a  clear  description  of 
chorea  major  occurring  successively  in  five  children  in  the  s;imc  fauiily. 
Dr.  Dewar,  the  attending  physician,  states  that  one  of  the  children  whom 
he  was  called  to  see  was  sitting  near  the  fireplace,  when  her  head  dropp.'d 
on  lier  chest,  and  she  appeared  to  doze  some  minutes.  In  the  mean- 
time the  res[)iration  became  a  little  accelerated,  the  face  altered  and 
fliislied,  the  eyes  wild.  In  less  than  one  minute  she  bounded  from  one 
extremity  of  the  aj)artment  to  the  other,  leaping  over  cliairs,  a  chest, 
and  tli<'ii  throwing  herself  upon  the  floor;  slie  attemptiMl  to  stand  upon 
her  head,  rolled  upon  the  floor,  and  then,  rising,  ran  witii  extreme  swift- 
ness in  the  room,  till  she  finally  fell  again  upon  the  floor,  where  she  re- 
mained motionless  some  minutes.     Then,  recovering,  she  noticed  those 


520  CHOREA. 

who  surrounded  lier,  and  asked  of  her  sister  a  tOT,  which  she  had  al- 
lowed to  fall.      The  whole  paroxysm  lasted  twenty  minutes. 

Obviously,  the  symptoms  of  chorea  major  differ  materially  from  those 
of  chorea  minor,  and  it  is  a  question  whether  it  should  have  the  same 
generic  name.  It  is  a  curious  and  interesting  disease  in  its  psychical 
and  pathological  aspects,  but  it  is  so  rare  in  modern  times  that  a  knowl- 
edge of  it  is  of  little  practical  importance. 

IxTESTiXAL  Irritatiox. — In  rare  instances  intestinal  worms  cause 
chorea,  though  in  these  cases  there  have  usually  been  some  cooperating 
causes.  The  following  is  an  example  related  by  Mr.  Ogle':  "Ellen 
L.,  9  years  old,  had  been  under  treatment  about  a  month  with  chorea, 
rheumatism,  and  worms.  She  had  not  slept  in  four  days,  and  there 
was  constant  spasmodic  movement  of  the  body  and  face.  Her  general 
condition  was  very  unpromising.  As  she  had  passed  portions  of  a  tape- 
worm at  intervals  during  the  last  three  months,  one  drachm  of  the  oleum 
filicis  maris  was  administered  in  mucilage,  which  caused  the  expulsion 
of  the  entire  worm.  From  that  tiuie  she  fully  and  rapidly  recovered 
from  the  chorea,  though  a  mitral  niuraiur  remained." 

Lesioxs  of  Braix  and  Spixal  Cord. — Although  we  reject  the 
theory  that  cerebral  emboli  are  the  common  cause  of  chorea,  and  believe 
that  in  a  large  majority  of  cases  there  are  no  cerebro-spinal  lesions, 
nevertheless  experiments,  and  also  occasional  cases,  establish  the  fact 
that  if  not  true  chorea,  at  least  choreiform  movements  now  and  then  re- 
sult from  a  structural  affection  of  the  nervous  centres. 

Experiments  on  certain  of  the  lower  animals  demonstrate  that  irregular 
muscular  movements  may  be  produced  by  traumatic  injury  of  certain 
portions  of  the  cerebro-spinal  axis,  as  the  corpora  quadrigemina,  crura 
cerebri,  pons  Varolii,  crura  cerebelli,  thalami  optici,  parts  of  the  medulla 
oblongata  and  the  upper  portion  of  the  spinal  cord.  Pressure  on  the  pro- 
jecting part  of  the  medulla  oblongata  of  an  acephalous  monster  also  causes 
convulsive  movements.  At  the  meeting  of  the  New  York  Academy  of 
Medecine,  April  20,  1871,  Professor  Post  related  the  case  of  a  child  who 
was  struck  over  the  occiput  with  a  billet  of  wood,  and  chorea  followed, 
due,  in  all  probability,  to  the  injury  of  the  brain  which  resulted. 

If  irrer^ular  muscular  movements,  choreic  or  choreiform,  result  from 
traumatic  injury  of  certain  portions  of  the  nervous  centres,  may  they 
not  also  occasionally  occur  from  lesions  of  the  same  j)arts  produced  by 
disease?  Sir  Benjamin  Brodie^  relates  the  case  of  a  choreic  girl,  dying 
in  St.  George's  Hospital,  in  whom,  after  a  careful  post-mortem  exami- 
nation, the  only  morbid  appearance  observed  was  a  tumor  the  size  of  a 
hazel-nut,  connected  with  the  pineal  gland.  Dr.  Broadbent'  described 
another  case  before  the  London  l*athological  Society,  in  which  a  tumor 
was  found  arising  from  the  centre  of  the  spinal  cord  ;  and  Chambers  one 
in  which  tubercles  Avere  embedded  in  the  cord.  Romberg  quotes  from 
Frerichs  a  case  in  which  the  medidla  oblongata  was  pressed  upon  by  an 
enlarged  odontoid  process ;  and  Dr.  Aitken*  one  in  Avhich  the  specific 

»  Lond.  Medico-Chir.  Kev.,  Jan.  1868. 

"  London  Lancet,  Dec.  19,  1810. 

'^  Trarii^actions  Loruloii  Pathi)l<)gical  Society,  vol.  xiii.  p.  24G. 

*  GlasiTow  Medical  Journal,  vol.  i. 


axatomical,  characters.  521 

gravity  of  the  thalamus  opticus  ami  corpus  striatum  was  greater  on  one 
side  than  on  the  other.  Rilliet  and  Barihez  relate  other  similar  cases, 
and  add:  '"We  may  conclude,  from  these  diiferent  cases,  that  there 
exist  two  species  of  chorea :  the  one  essentially  a  simple  neurosis,  while 
the  other  depends  on  an  alteration  of  the  encephalo-rachidian  system. 
In  a  word,  it  is  of  chorea  as  of  convulsions,  that  it  is  sometimes  idio- 
pathic, sometimes  symptomatic."  Still,  the  cases  in  Avhicli  it  is  symp- 
tomatic are  so  few,  that  it  is  proper  to  consider  chorea,  as  it  ordinarily 
occurs,  one  of  the  neuroses  until  the  microscope  detects  some  anatomical 
cause  in  the  cerebro-spinal  system  of  which  we  are  now  ignorant. 

Anatomical  Characters. — We  have  seen  that  chorea  has  no  con- 
stant anatomical  characters.  Lesions  which  probably  sustain  a  causa- 
tive relation  to  the  disordered  muscular  action  are  sometimes  present, 
and  others  are  sometimes  observed  Avhich  are  neither  a  cause  nor  result, 
tlieir  presence  being  a  coincidence.  But  there  are  two  lesions  which, 
though  often  absent,  have  been  observed  in  so  large  a  proportion  of 
fatal  cases  that  they  are  justly  regarded  as  an  occasional  result  when 
chorea  is  severe.  Dr.  Hughes,  of  London,  collected  records  of  the  post- 
mortem appearances  of  14  cases,  with  the  following  result  as  regards  the 
cerebro-spinal  axis  :  Brain,.  1 4  cases  :  healthy,  4  cases ;  only  congested, 
3  cases ;  softened  in  part  or  entirely,  6  cases  (some  of  these  G  also  con- 
gested). In  some  of  the  14  cases  those  occasional  results  of  congestion, 
to  wit,  transudation  of  serum  and  extravasation  of  blood,  in  greater  or 
less  quantity,  were  also  observed.  Spinal  cord  :  healthy,  3  cases  ;  con- 
gested, 2  cases  (one  slightly,  in  the  other  the  engorged  vessels  were 
large  and  numerous);  softening  in  medulla  oblongata,  1  case;  softening 
opposite  fourth  and  fifth  vertebn^,  12  cases.  In  one  there  was  soft,  in 
another  firm  adhesion  of  the  spinal  meninges,  and  in  one  it  is  stated 
that  the  rachidian  fluid  was  opaque.  Of  sixteen  fatal  cases  of  chorea 
occurring  in  St.  George's  Hospital,  "  congestion  (more  or  less  com- 
plete) of  the  nervous  centres  (brain  or  spinal  coi-d,  or  both)  was  met 
with  in  six  cases."  Softening  of  certain  parts  of  the  brain  was  observed 
in  one  case,  and  of  the  spinal  cord  in  another.^  Other  statistics  of  the 
anatomical  character  of  fatal  chorea  correspond,  in  the  main,  with  those 
of  Hughes  and  Ogle.  The  lesions  observed  by  them  are  probably  not 
present  in  ordinary  cases,  occurring  only  when  the  choreic  movements 
are  so  severe  that  the  ])atierit  is  deprived  of  needed  repose,  and  the  im- 
portant functions  of  the  economy,  as  the  circulation  and  nutrition,  are 
seriously  disturbed. 

The  post-mortem  examination  of  other  parts  besides  the  cerebro- 
spinal axis  furnishes  a  negative  result,  if  we  except  such  affections  as 
have  been  ascertaine<l  to  act  as  causes  of  chorea.  What  portion  of  the 
nervous  centre  is  chiefly  involved  in  chorea  is  uncertain."  Some,  as  Sir 
Benjamin  C.  Brodie,^  consider  chorea  a  disease  of  the  nervous  system 
generally,  while  others  have  attributed  it  to  disease  or  disorder  of  a 
certain  part,  as  the  corpus  striatum,  cerebellum,  etc.  Finally,  it  is 
stated  that,  in  late  experiments  on  choreic  dogs,  the  movements  do  not 

1  Ogle,  Brit,  and  For.  Mpdiro-Chir.  Kev.,  Jan.  1868. 
*  London  Lancet,  Dec.  19,  18iO. 


522  CHOREA. 

cease  when  the  spinal  cord  is  sevei-ed  from  the  brain,  nor  also  on 
division  of  the  posterior  roots  of  the  spinal  nerves.^  In  these  cases, 
therefore,  the  part  of  the  axis  which  is  in  foult  would  appear  to  be  solely 
the  sj)inal  cord. 

Symptoms. — Chorea  is  partial  or  general.  It  is  partial  when  it 
affects  a  few  muscles,  or  groups  of  muscles,  as  those  of  one  arm,  tlie 
face  or  neck,  or  of  one  eye.  It  is  designated  general,  when  all  the 
limbs,  and  certain  of  the  muscles  of  the  face  and  trunk,  are  involved. 
Statistics  show  that  partial  chorea  occurs  more  frequently  on  tlie  left 
than  on  the  right  side,  and  in  general  chorea  the  movements  on  tlie  left 
side  usually  predominate.  The  commencement  is,  in  most  cases,  gradual. 
Even  when  finally  chorea  becomes  general,  certain  muscles  only  are 
affected  in  the  commencement  in  ordinary  cases.  The  child  in  whom 
tliis  disease  is  about  to  begin  is  observed  to  be  fretful  and  impatient  from 
slight  causes,  and  the  irregular  muscular  action  at  first  is  apt  to  be  mis- 
understood by  the  parents,  who  reprimand  him  for  his  supposed  fidgety 
hal)it.  In  exceptional  instances,  especially  Avlien  the  cause  is  a  sudden 
and  profound  emotion,  the  commencement  is  abrupt,  and  the  disease  is 
severe  and  general  from  the  first. 

In  a  majority  of  cases  the  muscles  which  are  primarily  affected  are 
those  of  the  face,  neck,  fingers,  or  hand  on  the  left  side.  Sydenham 
erred,  unless  the  clinical  history  of  chorea  has  changed  during  the  last 
two  centuries,  when  he  stated  as  the  common  fact  that  a  tottering  gait  is 
its  first  manifestation  ;  but  now  and  then  such  a  case  does  occur.  When- 
ever choreic  movements  appear,  other  muscles  besides  those  first  affected 
are  soon  inv^olved,  so  that  in  the  course  of  a  few  weeks,  sometimes  of  a 
few  days,  all  the  muscles  tliat  participate  are  engaged. 

A  muscle  affected  by  chorea  alternately  contracts  and  relaxes,  but 
less  forcibly  and  rapidly  than  in  eclampsia,  and  the  movement  is  partly 
controlled  by  volition.  This  produces  an  unsteady  and  tremulous 
action  of  the  part,  v/hether  a  limb,  the  neck  or  face,  which  at  once 
arrests  attention,  and  indicates  the  nature  of  the  disease.  The  result  is 
similar,  as  regards  the  muscular  action,  whether  the  patient  wills  a 
movement,  or  attempts  to  control  those  which  chorea  produces. 

If  the  case  be  of  ordinary  severity,  the  movements  continue  with  but 
momentary  intermissions,  except  during  sleep,  when  they  ordinarily 
cease.  In  grave  cases  patients  are  often  deprived  of  the  proper  amount 
of  sleep,  in  consequence  of  the  severity  and  persistence  of  the  muscular 
action,  and  in  exceptional  instances,  especially  when  the  result  is  fatal, 
the  movements  continue  in  sleep,  but  the  sleep  is  not  sound,  and  is  fre- 
quently interrupted.  In  profound  sleep,  the  muscles  are  always  in 
repose. 

The  older  writers  have  left  us  graphic  descriptions  of  those  diseases 
which  have  striking  external  manifestations,  though  often  with  some- 
what of  exaggeration.  Sydenham  says  of  chorea  :  "The])atient  cannot 
keep  it  (his  hand)  a  moment  in  the  same  place ;  whether  he  lay  it  upon 
his  breast,  or  any  other  part  of  his  body,  do  what  he  may,  it  will  h& 

^  Legros  et  Onimus,  Rech.  sur  Ips  inouvements  choreiformes  du  chien,  Acad,  dea 
Sci.,  9  Mai,  1870,  Lyons  Med.  Jour.,  June  5,  1870. 


sYMPTo:srs,  523 

jerked  elsewhere  convulsively.  If  anv  vessel  filled  with  drink  be  put 
into  his  hand,  before  it  reaches  his  mouth,  he  will  exhibit  a  thousand 
gesticulations,  like  a  mountebank.  He  holds  the  cup  out  straight,  as  if 
to  move  it  to  his  mouth,  but  has  his  hand  carried  elsewhere  by  sudden 
jerks.  Then,  perhaps,  he  contrives  to  bring  it  to  his  mouth,  and  if  so, 
he  Avill  drink  the  liquid  oif  at  a  gulp,  just  as  if  he  were  trying  to  amuse 
the  spectators  by  his  antics  !  " 

In  severe  general  chorea  a  similar  description  is  applicable  to  the 
movements  of  the  legs  and  features.  Grimaces  and  distortions  of  the 
features  occur,  while  the  gait  is  halting  and  unsteady,  or  it  is  impossible 
to  walk,  and  the  patient  lies  or  sits.  The  speech  is  slow,  thick,  and 
indistinct,  in  consequence  of  the  muscles  of  the  tongue  and  larynx  be- 
comintT  engaged,  and  even  mastication  and  deglutition  are  rendered  diffi- 
cult. The  imperfect  speech  in  chorea  is  attributed  partly,  however,  to  the 
mental  state  in  severe  protracted  cases.  Chorea,  except  Avhen  mild,  is 
accompanied  by  other  symptoms  referable  to  the  nervous  system.  More 
or  less  impairment  of  the  mental  facidties  occurs  in  chronic  cases  when 
severe,  exliibiting  itself  in  dulncss  or  apathy.  The  countenance  some- 
times presents  in  aggravated  cases  almost  the  appearance  of  idiocy.  The 
muscles,  instead  of  becoming  hypertrophied  and  more  powerful  by  their 
frequent  contraction,  grow  softer,  more  flabby,  and  weaker.  Indeed,  a 
partial  ])aralysis  sometimes  results,  so  that  a  degree  of  numbness  is  ex- 
perienced in  the  affected  part,  and  the  limb  when  raised  cannot  be  sus- 
tained. Pain  is  not  a  symptom  of  chorea,  but  fugitive  rheumatic  or 
neuralgic  pains  are  sometimes  exi)erienced.  Derangement  of  the  diges- 
tive function,  exhibited  by  a  poor  or  capricious  appetite,  constipation,  etc., 
are  common. 

In  rare  instances  chorea  affects  the  respiratory  muscles  so  as  to  pro- 
duce a  peculiar  involuntary  barking  or  squeaking  voice  by  the  forcible 
expulsion  of  air  over  the  tense  vocal  cords.  In  a  case  treated  by  Dr. 
L.  C.  Gray,  in  the  N.  Y.  Polyclinic,  the  patient,  a  boy  of  fifteen  years, 
had  been  choreic  since  his  seventh  year,  and  chorea  in  its  usual  form 
h.:d  continued  one  year  Avhen  the  barking  sound  commenced,  and  this 
has  continued  until  the  present  time.  Dr.  French,  of  Brooklyn,  also 
treated  a  similar  case,  having  the  folloAving  history  :  A  boy  of  nine 
years,  had  choreic  twitchings  of  the  facial  muscles  at  the  age  of  five 
vears.  After  continuing  several  months  they  ceased  during  an  entire 
winter,  after  which  the  peculiar  sound  of  the  voice,  resembling  the 
scjucak  of  a  young  turkey,  commenced.  It  occurred  at  the  beginning, 
midlife,  or  end  of  respiration.  It  alternated  with  choreic  movements  of 
otiier  ])arts  of  tlie  system,  so  that  when  they  ceased,  it  returned.  By 
the  laryngoscope,  the  irregular  action  of  the  vocal  cords  was  observed, 
but  the  expiratory  muscles  of  the  chest  were  also  involved^  so  as  to 
produce  the  peculiar  sound  by  the  forcible  expulsion  of  air.  In  Dr. 
French's  case  these  vocal  sounds  ceased,  except  at  rare  intervals  after 
three  montlis  of  medicinal  treatment.' 

Tlio  mine  of  choreic  patients  has  been  examined  ])y  Drs.  Walsh,  Ford, 
Beuce  Jones,  Handfield  Jones,  Radcliffe,  and  othei-s,  and  its  elements 

»  N.  Y.  Mod.  Record,  Dec.  l.J,  1883,  Dr.  Chapin. 


524  CHOREA. 

have  been  found  in  most  cases  to  vary  from  their  normal  quantity.  Dr. 
Handfield  Jones^  read  a  paper  before  the  Clinical  Society  of  London,  in 
1871,  on  two  cases  of  chorea  in  Avhichhe  had  made  careful  chemical 
analysis  of  the  urine,  with  the  following  result:  During  the  height  of 
the  disease  the  amount  of  the  urine  was  much  in  excess  of  what  it  was 
when  the  disease  had  ceased ;  the  urea  excreted  duiing  the  choreic 
period  was  in  excess,  as  was  also  the  phosphoric  acid  excreted  when  the 
choreic  symptoms  were  at  their  maximum,  but  the  quantity  of  this  acid 
was  less  than  the  average  during  convalescence;  a  moderate  amount  of 
uric  acid  during  the  disease  Avas  also  observed,  but  none  u])on  recovery. 

PiKHiNOSis — Course. — Chorea,  though  obstinate  and  often  incurable 
in  adults,  usually  terminates  favorably  in  children  in  two  to  four  months. 
Bouchut  considers  its  ordinary  duration  at  from  thirty  to  fifty  days, 
which  is  certainly  shorter  than  the  average  duration  in  this  country, 
except  wlien  the  disease  is  materially  abridged  by  treatment.  The  same 
author  states  that  it  may  continue  only  a  few  days,  as  he  has  observed 
in  cases  Avhich  occurred  during  convalescence  from  scarlet  fever.  But 
tremulousness  of  the  muscles  occurring  in  the  state  of  weakness  follow- 
ing a  grave  disease,  and  abating  as  the  general  health  is  restored,  I 
should  not  consider  as  properly  choreic,  any  more  than  that  occurring 
from  over-fatigue.  As  the  choreic  movements  gradually  increase  in  the 
initial  period  till  a  certain  maximum  is  reached,  so  their  decline  is 
gradual.  Temporary  variations  also  occur  througliout  the  disease  as 
regards  the  extent  of  the  movements,  which  are  aggravated  by  mental 
excitement,  bodily  fatigue,  certain  functional  derangements,  especially 
of  digestion,  and  sometimes  from  causes  which  are  not  apparent. 

Tliough,  as  a  rule,  chorea  in  children  ordinarily  terminates  fiivorably 
under  different,  and  even  injiu'ious  modes  of  treatment,  there  are  excep- 
tional cases.  Romberg  relates  tlie  history  of  a  |)atient  Avho  died  at  the 
age  of  seventy-six  years,  having  had  chorea  since  the  age  of  six  years. 
In  chorea  limited  to  a  few  muscles,  or  a  group  of  muscles,  the  prognosis 
is  more  doubtful  than  Avhen  it  affects  a  large  number,  since  in  the  former 
case  the  cause  is  more  likely  to  be  some  lesion  of  the  cerebro-spinal  axis. 
Thus  chorea  involving  only  certain  muscles  of  the  neck  or  of  the  eyes  is 
sometimes  due  to  this  cause,  and  is  then  very  obstinate. 

Again,  observatiojis  demonstrate  that  chorea,  when  at  first  in  all 
probability  strictly  a  neurosis,  but  of  a  protracted  and  grave  character, 
may  give  rise  to  a  central  organic  disease.  This  is  the  course  of  most 
of  the  fatal  cases,  congestion,  softening,  or  other  lesion  occurring  over  a 
greater  or  less  extent  of  the  nervous  centres.  Radcliffe  has  known 
cerebral  meningitis  to  supervene  in  two  instances.  With  the  occurrence 
of  a  lesion  of  the  cerebro-spinal  axis  now  symptoms  arise,  such  as  liead- 
ache,  convulsions,  delirium,  and  paralysis,  and  the  choreic  movements 
cease  or  continue,  according  to  the  nature  of  the  lesion. 

Chorea,  like  certain  other  diseases,  either  of  a  nervous  character  or 
having  a  nervous  element,  is  more  or  less  modified  by  intercurrent  in- 
flammatory and  febrile  affections.  The  oft-quoted  expression  from  Hip- 
pocrates, fehris  accedens  solvit  spasmos,  observations  show  to  be  founded 

^  London  Lancet,  July,  1871. 


T  K  E  A  T  M  E  X  T  .  525 

in  fact,  the  most  frequent  example  of  -svlnch  occurs  in  pertussis.  In 
cliorea  the  movements,  as  a  rule,  are  either  rendered  milder  or  they 
cease  as  long  as  the  febrile  excitement  continues  ;  hut  there  are  excep- 
tions, and  ihe  subsequent  course  of  the  disease  is  not  modified. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases.  The  irregular 
movements,  Avith  consciousness  preserved,  enable  us  to  make  a  diagnosis 
at  sight.  In  its  commencement,  and  Avhen  it  continues  in  an  unusually 
mild  form,  chorea  may  be  overlooked  by  the  physician,  as  it  often  is 
bv  the  parents,  the  movements  being  attributed  to  a  fidgety  habit :  but 
medical  advice  is  seldom  sought  till  the  movements  are  so  pronounced 
that  it  is  impossible  to  err,  except  through  gross  ignorance  or  care- 
lessness. 

It  is  important  to  determine  Avhen  chorea  merges  in  an  organic  dis- 
ease, and  also  Avhether  there  is  a  local  cause  of  the  cliorea.  A  careful 
and  intelligent  study  of  the  symptoms  and  history  of  the  case  is  re(|uisite 
in  order  to  a  correct  diagnosis  in  these  particulars. 

Treatment.  Regimenal. — As  chorea  in  a  large  proportion  of  cases 
occurs  in  a  state  of  anaemia,  and  the  vital  forces  are  ordinarily  more  or 
less  reduced,  obviously  the  regimen  should  be  such  as  invigorates  the 
system.  Fresh  air  and  outdoor  exercise,  active  or  passive,  according  to 
circumstances,  with  the  avoidance  of  undue  excitement,  are  re(|uisite, 
and  the  diet  should  be  nutritious,  but  plain  and  unirritating.  The 
various  functions  should  be  preserved  so  far  as  possible  in  their  normal 
state.  In  exceptional  instances,  "when  the  choreic  movements  are  violent, 
the  patient  should  lie  in  bed,  and  the  muscular^  action,  if  so  constant  and 
excessive  as  to  deprive  him  of  the  requisite  sleep,  should  be  restrained 
by  light  and  wellqtadded  splints. 

Medicinal. — Sometimes  among  the  cooperating  causes  is  one  of  a  local 
nature,  which  is  susceptible  of  removal,  as  a  carious  and  painful  tooth, 
intestinal  worms,  etc.,  and  measures  calculated  to  effect  this  are  ob- 
viously required.  Allusion  has  already  been  made  to  a  c;use  in  Avhich 
the  employment  of  the  oleo-resina  filicis  and  the  expulsion  of  a  tape- 
worm effected  a  speedy  cure. 

The  remedy  which  has  been  most  employed  in  chorea,  and  wliich  in 
consequence  of  the  aniTemia  is  plainly  indicated  in  a  large  proportion  of 
cases,  is  iron.  It  does  not  interfere  with  the  employment  of  other 
remedies  which  have  a  more  specific  effect.  Nearly  all  tiie  ferruginous 
preparations  have  been  prescribed  in  different  cases  with  benefit.  Rad- 
cliffe  gives  the  preference  to  the  iodide  of  iron,  believing  that  iodine,  as 
well  as  iron,  exerts  a  curative  influence.  I  have  of  late  inclined  to  the 
use  of  the  ammonio-citrate,  as  it  is  easy  of  administration  in  simple 
syrup,  and  is  well  tolerated. 

But  iron  must  not  be  regarded  as  the  main  remedy,  but  rather  as  an 
adjuvant.  Observations  during  the  last  fbw  years  in  both  continents 
have  more  and  more  established  the  claims  of  arsenic  to  be  regardetl  as 
the  most  efficacious  of  all  medicinal  agents  in  the  treatment  of  chorea. 
Properly  administered,  it  abridges  the  duration  of  this  disease  more 
certainly  than  any  other  agent,  and  within  a  few  days  begins  to  modify 
the  choreic  movements  in  the  severest  cases.  It  is  conveniently  given 
in  the  form  of  Fowler's  solution.     It  is  better  tolerated  by  children 


526  CHOREA. 

than  adults,  and  should  be  administered  to  them  in  a  larger  propor- 
tionate dose.  A  child  of  eight  years  can  take  five  drops,  diluted  in 
water,  three  times  daily  after  eating,  and  the  dose  may  be  increased  if 
needed  to  eight,  ten,  twelve,  or  even  fifteen  drops.  1  have  seldom  ob- 
served any  gastric  irritability  or  other  unpleasant  effect  from  its  use 
when  it  is  administered  largely  diluted  and  after  the  meals,  but  if  such 
occur,  it  should,  of  course,  be  suspended  for  a  time. 

While  not  hesitating  to  recommend  iron  and  arsenic  as  superior  to  all 
other  medicines  in  the  treatment  of  chorea,  it  is  not  pro])er  to  ignore 
the  opinions  of  other  members  of  our  jjrofession,  who  have  had  ample 
experience  and  recommend  other  agents  instead. 

Trousseau  gave  the  preference  to  strychnine,  increasing  the  doses  in 
some  cases  until  it  began  to  produce  its  poisonous  effects. 

Professor  Hammond  ^  says  :  "  My  main  reliance  is  on  strychnia, 
which,  I  think,  should  be  given  in  gradually  increasing  doses,  some- 
what after  the  manner  recommended  by  Trousseau.  .  ,  .  This 
plan  of  treatment  certainly  shortens  the  duration  of  the  disease  very 
materially,  and  causes  great  improvement  in  the  general  health  of  the 
patient.  Sometimes  tlie  effect  is  so  well  marked,  and  is  so  immediate, 
that  it  is  not  necessary  to  increase  the  doses  to  the  extent  of  causing 
muscular  cramps,  but  generally  the  full  therapeutical  efiect  of  the  drug 
is  not  obtained  till  the  calf  of  the  leg  or  the  nucha  has  slight  tonic  spasm. 
I  have  never  seen  the  slightest  ill-consequence  follow  this  mode  of  treat- 
ment, and  the  doses  are  increased  so  gradually  that  with  careful  watch- 
ing danger  need  not  be  apprehended."  Dr.  Hammond  has  treated 
thirty-two  children  with  this  agent  without  a  single  failure. 

But  as  chorea  terminates  favorably  with  smaller  and  safe  doses,  even 
if  the  time  required  be  longer,  it  docs  not  seem  proper  to  recommend  its 
employment  to  the  extent  of  producing  physiological  effects  for  genei-al 
practice.  Bouchut,  speaking  upon  this  point,  says:  "But,  with  these 
precautions,  strychnia  is  extremely  daugerous,  for  I  have  seen,  at  the 
Hopital  des  Enfants  Malades,  a  young  girl  of  thirteen  years  die  in 
tetanus,"  produced  by  an  increased  dose  of  this  drug  (article  on  Chorea). 
Dr.  West,  in  his  Lumleian  Lectures,  also  says:  "I  have  seen  one  in- 
stance in  which  its  employment,  while  it  failed  to  benefit  a  somewhat 
severe  case  of  chorea,  Avas  followed  by  two  attacks  of  violent  tetanic 
convulsions,  which  nearly  proved  fatal;"  and  he  adds,  "The  twitching 
of  the  limbs  of  itself  prevents  our  becoming  aware  of  the  dose  being 
excessive,  and  a  child's  inability  to  describe  its  sensations  deprives  us 
of  another.  For  such  reasons,  Dr.  West  does  not  favor  the  employ- 
ment of  this  agent.  Still,  any  agent  may  be  given  in  an  overdose,  and 
it  is  not  difiicult  to  prescribe  strychnia  in  a  dose  which  will  be  efficient 
and  yet  safe  for  children  at  the  age  at  which  chorea  ordinarily  occurs. 
I  have  employed  bromide  of  potassium  in  a  few  cases,  but  with  so  little 
benefit  that  I  am  not  inclined  to  continue  its  use  for  this  disease. 
Others  have  not  been  more  successful.  However  efficacious  the  bromide 
may  be  in  epilepsy,  it  does  not  appear  to  be  a  remedy  for  chorea. 

Cimicifuga,  first  employed  by  Jesse  Young,  of  this  country,  is  highly 

^  Diseases  of  the  Nervous  System,  page  (317. 


TREATMENT.  527 

esteemed  by  Philadelphia  physicians  in  the  treatment  of  chorea.  I 
have  employed  the  fluid  extract  in  doses  of  half  a  drachm,  increased  to 
one  drachm,  for  a  child  from  six  to  ten  years  of  age,  and  though  it 
benefits  some  cases,  it  has  no  appreciable  effect  either  in  moderating  the 
movx-ments  or  abridging  the  duration  of  others. 

Ether,  asafoetida,  valerian,  musk,  the  oxide  and  sulphate  of  zinc,  tur- 
pentine, tartar  emetic,  opium,  and  numerous  other  remedies,  have  been 
recommended,  and  some  of  them  have  seemed  usefid  in  certain  cases. 
Li  this  city  sulphate  of  zinc  has  been  frequently  employed  as  a  remedy 
f>r  chorea,  and  in  gradually  increasing  do?es  till  more  than  twenty 
grains  were  administered  three  times  daily,  but  it  has  not  appeared,  so 
far  as  I  have  been  able  to  ascertain,  to  exert  any  marked  influence 
either  on  the  severity  or  duration  of  the  choreic  movements.  Justice, 
however,  requires  us  to  state  that  Dr.  West,  who  has  written  recently 
on  the  nervous  diseases  of  children,  thinks  that  it  has  been  beneficial  in 
certain  cases  in  which  he  has  employed  it,  and  he  regards  it  on  the  whole 
as  the  best  remedy. 

Radcliffe,  who  has  had  ample  experience  in  the  treatment  of  nervous 
affections,  writes:  "In  an  ordinary  case  of  chorea  the  plan  of  treat- 
ment which  I  have  now  adopted  as  a  rule  for  some  time  is  to  give  cod- 
liver  oil,  in  conjunction  with  hypophosphite  of  soda,  making  the  draught 
containing  the  latter  salt  the  vehicle  for  the  administration  of  the  cod- 
liver  oil."  Sometimes  camphor  or  the  sesquicarbonate  of  ammonia  is 
added.  Of  more  than  thirty  cases  treated  in  this  Avay,  the  average 
duration  was  under  three  weeks.  Radcliffe  began  to  prescribe  these 
remedies  on  theoretical  grounds,  believing  that  pliosphorus  and  cod- 
liver  oil  were  re(|uired  to  restore  "nerve  tone,"  and  the  result  of  this 
treatment  has  certainly  been  such  as  to  commend  it  to  the  profession. 
To  children  he  gives  from  five  to  eight  grains  of  the  hypophosphite  of 
sodium  three  times  daily. 

In  those  severe  cases  in  which  choreic  movements  prevent  the  proper 
amount  of  sleep,  a  moderate  dose  of  hydrate  of  chloral  may  occasionally 
be  arlvantageously  administered. 

Electricity  has  been  many  times  employed  in  the  treatment  of 
cliorea,  and  though  some,  chiefly  electricians,  believe  that  it  has  a 
curative  effect,  others,  and  the  majority,  fail  to  see  any  material  benefit 
from  its  use. 

Col<l  general  baths,  the  shower-bath,  frictions  along  the  spine,  etc.,  have 
been  employed ;  but  tlie  local  treatment  wiiicli  has  so  far  been  most  success- 
fid,  and  which  promises  to  supersede  all  other  local  measures,  consists  in 
the  application  of  ether  spray  over  the  spine.  About  two  ounces  of 
ether  are  employed  at  each  sitting,  the  spray  being  applied  from  an 
atomizer  up  and  down  the  whole  length  of  the  spine  if  the  chorea  be 
general.  The  operation,  which  occupies  from  ten  to  fifteen  minutes, 
should  be  repeated  daily  or  every  second  day.  A  considerable  nund)er 
of  cases  have  been  reported,  in  which  the  spray  has  apparently  had  a 
good  effect  in  controlling  the  disease.  But  I  repeat  my  belief,  from 
the  large  num1)er  of  cases  seen  in  the  Bureau  for  the  Relief  of  the 
Outdoor  Poor,  that  the  arsenical  and  ferruginous  treatment  gives  more 
satisfaction  than  any  or  all  other  measures. 


528  INFANTILE    PARALYSIS. 


CHAPTER    XY. 

INFANTILE  PARALYSIS. 

Paralysis  in  young  children,  especially  infants,  is  in  most  instances 
due  to  causes  which  seldom  produce  it  in  adults.  The  principal  cause 
of  it  in  the  adult,  namely,  cerebral  apoplexy,  is  indeed  rare  in  children. 
Paralysis  in  children  has  the  following  recognized  causes:  1st.  A 
change  in  the  blood,  not  fully  understood,  induced  by  certain  grave  dis- 
eases, as  diphtheria,  typhoid  fever,  measles,  scarlet  fever,  etc.  2d.  Re- 
flex influence.  The  function  of  some  part  of  the  system  is  in  some 
way  disturbed,  and  paralysis  occurs  in  certain  muscles,  perhaps  at  a 
distance  from  the  cause,  and  it  disappears  when  that  cause  is  removed, 
unless  it  liave  continued  too  long.  The  only  rational  explanation  is 
found  in  the  fact  of  a  continuous  connection  between  the  local  cause 
and  the  paralyzed  muscles  through  the  aff"erent  and  efferent  nerves,  and 
the  nervous  centres.  3d.  Compression  or  injury  of  a  nerve-trunk. 
These  cases  are  rare.  Pressing  of  the  portio  dura  by  the  blades  of  for- 
ceps during  birth,  described  in  the  next  chapter,  is  an  example.  4th. 
An  anatomical  alteration  in  the  muscular  fibres,  the  nerves  and  nervous 
centres  remaining  unaffected.  This  has  been  designated  myogenic 
paralysis.  This  form  of  paralysis  is  probably  often  of  a  rheumatic 
nature.  Paralysis  of  the  face  or  other  portions  of  the  surfiice,  which 
sometimes  occurs  in  children  and  adults  from  prolonged  exposure  to 
cold  winds,  is  of  this  nature.  5th.  Some  anatomical  change  in  the 
nervous  centres,  as  congestion,  hemondiage,  inflammation,  emboli, 
compression  and  laceration  of  brain,  whether  by  tumors,  inflammatory 
products,  or  other  causes,  etc.  If  there  be  hemiplegia  the  presumption 
is  that  the  disease  causing  it  is  cerebral ;  if  paraplegia,  that  it  is  spinal. 
The  following  is  a  interesting  example  of  hemiplegia.  The  case  was 
related  by  me,  and  the  specimen  presented  to  the  New  York  Patho- 
logical Society. 

Case. — Maggie,  aged  2  years  8  months,  was  admitted  into  the  Catholic 
Foundling  Asylum  about  the  1st  of  September,  1874.  She  seemed  to  be 
in  good  health  and  was  plump  and  well  developed,  and  her  mother  stated 
that  she  had  had  no  serious  sickness.  After  her  admission  she  continued 
well,  having  the  usual  appetite,  amusing  herself  through  the  day,  and 
presenting  no  symptoms  to  attract  attention  till  December  Gtli.  On  the 
evening  of  December  5th  she  ate  her  supper  as  usual,  and  was  placed  in 
her  crib,  apparentli/  in  perfect  health.  At  3  A.  M.,  the  sister  who  was  in 
charge  of  the  ward  found  her  in  severe  general  eclampsia.  Immediately, 
in  addition  to  the  usual  local  treatment,  she  administered  five  grains  of 
bromide  of  potassium,  and  this  was  repeated  at  intervals  till  six  or  seven 
doses  were  administered.  Nevertheless,  the  s})asmodic  movements  con- 
tinued, with  more  or  less  violence,  till  1}  p.  M.,  and  in  the  muscles  of  the 
lee  somewhat  lone:er. 


CASE.  529 

On  my  arrival  at  the  asylum,  at  about  6  p.  :\i.,  I  found  her  lying  quietly, 
rather  stupid,  but  easily  aroused.  Her  vision  \vas  evidently  good,  and 
she  was  conscious ;  the  pupils  responded  to  light,  and  the  direction  of  the 
eyes  was  normal ;  pulse  104,  no  cough,  and  respiration  natural ;  tempera- 
ture, as  ascertained  by  the  thermometer  in  the  axilla,  also  normal.  There 
was  no  apparent  paralysis  of  the  muscles  of  the  face,  but  the  right  arm 
and  leg  were  paralyzed,  though  the  paralysis  was  not  complete.  The 
great  toe  flexed  on  tickling  the  sole  of  the  foot,  but  the  foot  itself  had 
little  or  no  motion,  and  on  my  attempting  to  flex  the  leg,  which  was  ex- 
tended, some  rigidity  of  the  muscles  was  observed.  At  times  the  patient 
produced  slight  movement  of  the  thigh  upon  the  trunk.  The  muscles  of 
tiie  right  upper  extremity  were  more  flaccid  than  those  of  the  leg,  and 
motion  of  tiie  forearm  was  totally  lost,  while  a  little  movement  remained 
of  the  arm  on  the  trunk.  During  the  two  or  three  days  succeeding  the 
convulsions  sensation  in  the  right  limbs  did  not  appear  to  be  entirely  lost, 
though  greatly  enfeel)led.  Subsequently  paralysis  in  the  right  limbs,  both 
of  the  nerves  of  sensation  and  motion,  was  nearly  or  quite  total,  and 
continued  so  till  death.  Nevertheless,  tickling  the  sole  of  the  foot  caused 
s<)me  movement  of  the  great  toe.  On  the  left  side  sensation  and  motion 
were  perfect. 

The  record  of  December  9th  runs :  Has  vomiting  to-day  for  the  first 
time ;  apparently  sees  well,  and  appearance  of  the  eyes  normal ;  has  no 
i-etraction  of  head,  or  rigidity  of  muscles  of  neck,  or  along  the  spine ; 
pulse  96,  temperature  in  the  axilla  normal;  lies  quiet  and  with  eyes  shut; 
is  stupid,  and  not  fretful  when  aroused;  the  bowels  move  regularly. 

December  11th,  continues  to  vomit  at  intervals;  pulse  68.  Dec.  16th, 
pulse  80,  tem])erature  100^ ;  vomited  once  yesterday,  none  to-day;  lies  in 
a  constant  doze ;  takes  bromide  of  potassium  gr.  iv  three  times  dailv. 
Dec.  18th,  moans  at  times,  as  if  in  pain;  ])ulse  180,  temperature  100""; 
takes  the  bromide  gr.  iv  every  four  hours. 

Dec.  19th,  pulse  180,  temperature  lO^P;  she  has  convergent  strabismus, 
and  the  eyes  have  a  wild,  almost  insane  look,  hut  she  sees,  grasping  hur- 
riedly the  percussion  hammer  presented  toward  her ;  paralysis  of  nerves 
of  motion  and  sensation  in  the  right  extremities  nearly  complete ;  slight 
movement  is  still  produced  in  the  great  toe  by  titillation ;  the  vomiting 
lias  ceased ;  tongue  covered  with  a  thick  fur ;  movements  of  the  bowels 
pretty  regular ;  has  a  slight  cough,  such  as  is  common  in  cerebral  disease. 

Dec.  2"2d,  lies  quietly  on  her  side  in  perpetual  slumber,  with  eyes  con- 
stantly shut;  pulse  118,  temperature  101]"  ;  the  bowels  still  move  nearly 
normally  ;  the  pupils,  exposed  to  the  light,  are  seen  to  oscillate,  but  are 
constantly  more  dihited  than  in  health  ;  the  urine  passes  freely  ;  circum- 
scribed fliisliing  of  the  features  at  intervals;  a  rash  like  lichen  over  abdo- 
men and  chest,  possibly  due  to  the  large  quantity  of  bromide  of  potassium 
administered.     24tli,  pulse  intermittent;  pupils  dilated. 

Dec.  2.")th,  died  in  prof  )und  stupor  to-day,  having  lived  nineteen  days 
from  the  commencement  of  the  maladv. 

Aidop.il/. — Al)out  thirty  hours  alter  death  ;  weather  cool.  On  removing 
the  calvarium  and  (];ira  mater,  which  presented  no  unusual  apjjearance, 
the  vessels  of  the  pia  mater  were  found  lather  more  injected  than  usual, 
l)ut  not  more  s  >  than  we  sometimes  observe  in  those  who  die  of  diseases 
which  do  not  involve  the  brain.  The  cerebro-spinal  fluid  w-as  scanty,  and 
the  surface  of  the  brain  rather  dry.  The  vertex  of  the  hit  hemisphere 
was  unusually  pronunent,  rising  perhaps  half  an  inch  higher  than  that  on 
the  opposite  side.     At  the  highest  point,  which  was  about  one  and  a  half 

34 


530  INFANTILE    PARALYSIS. 

inches  from  the  median  line,  wa.s  a  circidar  yellowish  spot  upon  the  sur- 
face of  the  brain  about  one  and  a  half  inches  in  diameter.  Pressure  upon 
this  spot,  made  lightly,  so  as  not  to  produce  ru])ture,  communicated  the 
sensation  of  a  large  cavity  underneath  filled  with  liquid,  and  approaching 
to  within  two  or  three  lines  of  the  surface.  There  was  no  adhesion  or  ex- 
udation over  this  spot;  and  the  surface  of  the  brain  appeared  entirely 
normal,  except  a  little  cloudiness  of  the  pia  mater  over  a  space  which 
could  be  covered  by  a  iive-cent  piece,  a  little  ])osterior  to  the  o]:)tic  com- 
missure. The  incised  surface  of  the  brain,  at  a  distance  from  the  abscess, 
showed  no  increase  of  vascularity.  The  right  hemis{)here  appeared  in 
every  way  normal,  except  that  its  lateral  ventricle  was  filled  with  pus,  but 
not  distcnded. 

On  the  left  side,  occupying  the  centre  of  the  hcmis])here,  was  an  abscess 
as  large  as  the  fist  of  a  child  of  two  years,  extending  from  Avithin  two  or 
throe  lines  of  the  vertex,  where  its  site  con'csponded  with  the  yellow  spot 
on  the  surflice  of  the  brain,  to  the  roof  of  the  lateral  ventricle.  Through 
this  roof  the  abscess  had  burst,  filling  and  distending  the  ventricle  with 
2)us,  and  thence  making  its  way  into  the  lateral  ventricle  of  the  opposite 
hemisphere.  The  whole  amount  of  pus  contained  in  the  abscess  and  the 
two  ventricles  was,  perhaps,  two  ounces.  The  walls  of  the  left  lateral 
ventricle  were  much  softened,  the  upper  part  of  the  corpus  striatum  and 
thalamus  opticus  being  nearly  diffluent ;  the  walls  of  the  right  lateral 
ventricle  were  slightly  softened,  but  to  less  depth.  The  parietes  of  the 
abscess,  which  extended  from  the  roof  of  the  ventricle  to  the  vertex,  as 
already  stated,  were  indurated  to  the  depth  of  one  and  a  half  lines  in  con- 
sequence of  proliferation  of  the  connective  tissue,  except  at  the  base  of  the 
abscess,  which  corresjjonded  with  the  roof  of  the  ventricle,  where  soften- 
ing had  occurred.  The  spinal  cord,  so  far  as  it  could  be  examined  from 
the  cranial  cavity,  had  the  usual  vascularity,  and  seemed  nearly  or  quite 
normal. 

The  cau>e  of  encephalitis  from  which  the  abscess  resulted  was  ob- 
scure. This  inflammation,  so  far  as  can  be  ascertained,  was  idiopathic, 
which  is  known  to  be  a  rare  disease.  There  was  no  history  of  otitis,  which 
is  one  of  the  most  frequent  causes  of  cerebral  abscess,  nor  of  heart  disease, 
so  as  to  produce  embolisui.  It  seems  probable,  since  there  w'as  no  fever 
till  about  the  fourth  day  after  the  convulsions,  that  an  abscess  hud  prim- 
arily occurred  in  the  hemisphere  batween  the  roof  of  the  ventricle  and  the 
vertex,  probably  weeks  previously.  The  bursting  of  this  into  the  lateral 
ventricles  and  the  constitutional  disturbance,  inflammation,  and  softening 
to  which  this  gave  rise  afford  sufficient  ex])lanatiou  of  the  history  of  the 
case  after  tbe  commencement  of  the  convulsions. 

Paralysis  occurring  as  a  symptom  or  sequel  of  some  obvious  local  or 
general  disease,  as  diphtheria,  lesion  of  the  nervous  centres,  etc.,  and 
which  may  occur  at  any  age,  need  not  detain  us.  It  is  described  in 
connection  with  tlic  primary  diseases  on  Avhich  it  depends.  But  there 
is  a  form  of  paralysis  which  in  the  present  state  of  our  knowledge  we 
must  consider  an  idiopathic  malady,  and  which  is  peculiar  to  the  first 
years  of  life,  or  is  so  rare  at  other  periods  that  it  is  proper  to  regard  it 
as  strictly  a  malady  of  infancy  and  early  childhood.  It  occurs  between 
the  ages  of  six  months  and  three  years.  The  following  description  re- 
lates to  it : 

Symptoms. — The  previous  health  of  the  patient  is  usually  good 
The  paralysis  does  not  always  commence  in  the  same  manner.     In  a 


I 


SYMPTOMS.  531 

few  instances  it  begins  suddenly  m  the  daytime  when  the  child  is  ap- 
parently in  perfect  health.  In  some  it  begins  abruptly,  after  sound 
sleep.  The  child  goes  to  bed  well,  sleeps  through  the  night,  and  awakens 
in  the  morning  paralyzed.  I  have  known  it  to  occur  in  one  instance 
after  sleep  in  the  middle  of  the  day.  In  these  cases  there  has  sometimes 
been  an  exposure,  before  the  sleep,  to  wind  or  rain,  or  from  sitting  upon 
a  cold  stone.  In  other  and  the  majority  of  cases  the  paralysis  is  pre- 
ceded by  a  very  decided  febrile  movement,  wdiich  comes  on  suddenly, 
without  appreciable  cause,  and  after  a  few  days  the  power  of  motion  is 
found  to  be  lost  in  one  or  more  of  the  limbs.  No  symptom  occurs 
during  tlie  febrile  movement  indicative  of  disease  of  the  brain :  conscious- 
ness is  retained,  and  there  is  no  more  headache  or  apparent  liability  to 
convulsions  than  is  present  in  other  pathological  states  accompanied  by 
an  equal  amount  of  fever.  The  paralysis  is  at  its  maximum  in  the  com- 
mencement. Occurring  as  by  a  stroke,  the  full  extent  of  the  paralytic 
state  is  exliibited  at  once,  and  so  far  as  there  is  any  subsequent  change, 
it  is  an  improvement,  as  regards  the  number  of  muscles  affected,  and  the 
degree  of  the  paralysis.  Most  frequently  the  muscles  of  one  or  both 
lower  extremities  are  affected.  Occasionally  one  of  the  upper  extremi- 
ties is  also  paralyzed  in  a»ldition  to  the  lower,  but  paralysis  of  an  upper 
extremity  is  less  in  degree,  and  disappears  sooner,  than  that  of  the  lower. 
The  bladder  and  lower  bowel  remain  unaffected,  since  only  the  muscles 
of  volition  are  involved.  Sensation  is  unimpaired  in  the  affected  limbs, 
and  in  the  commencement  there  is  even  in  some  cases  a  state  of  hy- 
peraesthesia  (West).  The  febrile  movement  which  precedes  and  accom- 
panies the  paralysis  in  certain  cases,  gradually  abates,  and  in  a  few  days 
nothing  abnormal  remains  except  the  loss  of  power  in  the  affected  mus- 
cles. These  muscles  are  in  a  flaccid  and  relaxed  state,  so  that  the  limb 
falls  by  its  weight  when  unsupported,  and  they  are  usually  free  from 
pain.  The  number  of  muscles  paralyzed  varies  greatly  in  different  cases. 
Only  one  muscle  or  a  single  group  of  muscles  may  be  affected,  or,  on 
the  other  hand,  both  the  extensor  and  flexor  muscles  of  two  or  more 
limbs  may  be  paralyzed.  In  the  opinion  of  Mr.  Adams,  the  following 
table  exhibits  tiie  groups  of  muscles  and  single  muscles  most  frequently 
involved,  and  in  the  order  stated: 

Groups. 

1.  Extensors  of  toes,  and  flexors  of  the  foot. 

2.  Extensors  and  supinators  of  the  hand. 

3.  Extensors  of  leg,  and  with  them  usually  the  first  group. 

Single  Muscles. 

1.  Extensor  longus  digitorum  of  toes. 

2.  Tibialis  anticus. 

3.  Deltoid. 

4.  Sterno-mastoid. 

The  f«dlowing  is  an  example  of  infantile  paralysis,  as  it  not  infre- 
quently occurs  when  the  result  is  favorable:  A.  K.,  German,  female, 
aged  3  years  4  months,  fleshy;  had  been  in  the  habit  of  sitting  on  the 


532  INFANTILE    PARALYSIS. 

ground  near  the  house  and  on  the  door-sill.  On  July  2,  1871,  she  had 
a  sound  sleep  in  the  afternoon,  having  been  entirely  well  previously, 
and  awoke  trembling  and  Avith  a  high  fever  at  3i  p.m.  At  8  p.m.,  the 
febrik'  excitement  continuing,  general  clonic  convulsions  occurred,  last- 
ing about  ten  minutes.  At  this  time  1  Avas  called  to  see  her,  and  lound 
her  face  flushed,  surface  hot,  and  pulse  about  one  hundred  and  thirty. 
Consciousness  returned  after  the  convulsion.  Her  intelligence  was  good, 
tongue  moist  and  slightly  furred,  bowels  rather  constipated,  and  the 
urine  freely  passed.  The  febrile  excitement  continued  two  days,  when 
it  gradually  and  entirely  abated,  but  before  it  ceased  paralysis  of  the 
left  lower  extremity  was  observed.  No  Aveight  at  first  could  be  sus- 
tained upon  this  limb,  and  it  hung  powerless  when  we  endeavored  to 
make  her  walk.  The  attempt  caused  her  to  cry,  as  if  in  pain,  and 
pressing  upon  the  thigh,  or  moving  it,  had  the  same  effect.  I'he  thigh 
of  this  limb  did  appear  slightly  swollen  on  inspection,  but  measurement 
did  not  indicate  any  notable  enlargement.  The  diflerence  in  circum- 
ference Avas  not  more  than  one-eighth  to  one-fourth  of  an  inch.  There 
Avas  no  appreciable  increase  of  heat  in  the  thigh  over  the  genersil 
temperature  of  the  body.  Sensibility  remained  in  every  part  of  the 
limb,  and  the  loss  of  power  Avas  not  complete,  for  on  the  first  day,  as 
soon  as  the  paralysis  Avas  observed,  slight  and  imperfect  movements 
could  be  produced  by  pinching  the  limb.  In  three  Aveeks  the  use  of 
the  limb  Avas  fully  restored,  by  mildly  stimulating  liniments,  and  simple 
medicines  to  regulate  the  bowels.  The  tenderness  Avhich  Avas  observed 
in  this  case  is  only  occasionally  present,  and  has  been  attributed  to 
liyperfBsthesia. 

Piiodxosis — Progress. — The  paralysis  in  nearly  all  cases  soon 
begins  to  abate.  The  power  of  motion  returns  little  by  little,  and  Avliat- 
ever  improvement  occurs  is  permanent.  There  is  no  retrogression  in 
the  convalescence.  The  sooner  improvement  commences,  the  more 
favorable  is  the  prognosis.  In  the  most  favorable  cases  there  is  com- 
plete restoration  in  from  three  to  four  Aveeks.  In  other  patients,  while 
certain  of  the  nniscles  regain  the  power  of  motion,  other  muscles,  oftener 
those  of  the  lower  extremity  than  upper,  do  not  recover  their  function, 
and,  unless  proper  remedial  measures  be  employed,  and  even  Avith  them 
in  certain  instances,  atrophy  soon  commences.  The  temperature  of  the 
paralyzed  limb  falls  three,  five,  or  CA-^en  eight  degrees,  and  the  amount 
of  blood  Avhich  circulates  in  it  is  diminished  so  that  the  pulse  of  the  limb 
is  feebler  and  its  vessels  smaller  than  in  health.  With  the  atrojjhy  the 
contract ilit}^  of  the  muscular  fibres  by  the  electric  current  diminishes, 
and  in  unfavorable  cases  after  a  time  poAverful  induced  and  even  primary 
currents  have  no  appreciable  effect.  The  nutrition  of  a  paralyzed  limb 
is  ahvays  imperfect,  and  if  the  paralysis  occur  in  a  child,  its  groAvth  is 
retarded.  Therefore,  in  cases  of  protracted  or  permanent  infantile  paral- 
ysis of  one  limb,  a  disproportion  occurs  both  in  diameter  and  length 
bctAveen  it  and  that  on  the  opposite  side.  If  the  paralysis  continue,  the 
ligaments  of  the  paralyzed  limb  become  relaxed  and  lengthened.  West 
mentions  a  case  of  paralysis  of  the  deltoid  in  Avliich  the  humero-scapular 
ligaments  Avere  so  extended  that  the  humerus  dropped  from  the  glenoid 
cavity,  so  as  to  increase  the  length  of  the  limb  three-fourths  of  an  inch. 


ETIOLOGY.  533 

In  the  i^aralysis  of  certain  muscles  of  the  lower  extremity,  and  contin- 
uance of  the  contractile  power  in  others,  Ave  have  the  conditions  which 
give  rise  to  club-feet,  and  accordingly  this  deformity  is  the  common 
result  of  the  paralysis  when  it  is  not  cured. 

Etiology. — As  infantile  paralysis  is  not  a  fatal  malady,  opportunity 
for  post-mortem  examination  in  a  recent  case  seldom  occurs.  Hence 
the  difficulty  in  determining  the  exact  anatomical  change  in  the  nervous 
system  which  produces  tlie  paralysis.  Medical  literature  contains 
records  of  a  considerable  number  of  cases  in  which  autopsies  have  been 
made,  but  death  occurred  so  long  after  the  commencement  of  the 
paralysis,  usually  months  or  years,  that  it  is  difficult  to  determine 
whether  lesions  which  have  been  observed  were  a  cause  or  consequence. 
In  a  majority  of  these  autopsies  a  spinal  lesion  of  some  sort  Avas  de- 
tected, but  in  some  instances  none  could  be  discovered. 

Mr.  Adams,  in  his  treatise  on  club-foot,  relates  a  case  in  which  the 
spinal  cord,  carefully  examined,  probably  only  Avith  the  naked  eye, 
seemed  normal.  Robin  examined  the  spinal  cord  microscopically  in 
one  case,  but  discovered  nothing  abnormal,  and  Elischer  made  autopsies 
in  two  cases  of  this  paralysis  in  Avhich  death  had  occurred  from  variola, 
but  Avith  a  negative  result  as  regards  lesions  in  the  nervous  system.^  The 
examinations  by  Robin  and  Elischer,  since  they  Avere  microscopic,  have 
been  justly  regarded  as  important,  and  they  have  been  related  by  Avriters 
in  order  to  sustain  the  theory  that  infantile  paralysis  is  peripheral,  and 
not  centric. 

Very  little  A\'as  effected,  prior  to  I860,  in  .determining  the  cause  or 
causes  of  infantile  paralysis  by  post-mortem  examinations,  because  the 
microscope  Avas  so  little  used,  and  because  in  most  of  the  cases  reported 
the  clinical  history  or  microscopic  lesions  Avere  such  as  to  show  or  to 
render  it  highly  probable  that  the  paralysis  Avas  not  such  as  is  designated 
and  understood  by  the  terra  infantile.  Thus  Beraud  reported  a  case  in 
Avhich  tubercles  Avere  found  in  the  spinal  cord.  Hutin,  a  case  in  Avhich 
there  was  atrophy  of  the  lower  part  of  the  spinal  cord,  but  the  paralysis 
commenced  at  the  age  of  seven  years.  Hammond,  a  case  in  Avhich  a 
clot  Avas  found  in  the  spinal  cord;  and  Jaccoud,  one  of  spinal  arachnitis, 
Avith  thickening  of  the  meninges.  Since  18G3,  se\Tnteen  autopsis  have 
been  recor«led  in  Avhich  the  s])inal  cord  Avas  carefully  examined,  and 
upon  these  Ave  must  chiefly  rely  for  our  data  by  Avhich  to  determine 
Avhat  are  the  anatomical  changes  in  the  nervous  system  Avhich  probably 
cause  this  paralysis.  The  reader  Avill  find  these  cases  tabulated  in  a 
lecture  by  E.  C.  Seguin,^  M.D.,  and  the  most  important  of  them  nar- 
rated in  a  paper  on  infantile  paralysis,  showing  great  research,  published 
by  Dr.  Mary  Putnam  Jacobi.*  It  is  true  that  all  but  three  of  these 
post-uiortem  examinations  Avere  made  many  years  after  the  occurrence 
of  the  paralysis;  but  in  the  three  cases  Avhich  Avere  reported  by  Roger 
and  Damaschino,  only  tAvo,  six,  and  thirteen  months  had  elapsed.  The 
following  Avcre  the  chief  lesions  observed  in  these  cases  as  regards  th'.' 
spinal  cold  : 

>  Jahrbuch  fiir  Kinderh.,  1873. 

»  N.  Y.  Med.  Record,  .Janimrv  IT,,  LS74. 

»  N.  Y.  (Jbst.  Journ.,  for  Miiv,  1874. 


534  INFANTILE    PARALYSIS. 

Cases. 

1.  Atrophy  of  motor-cells  in  anterior  cornua  .         .         .         .10 

2.  Nerve-cells,  normal     .........     2 

3.  Atrophy  (variously  recorded)  of  anterior  column-;,  or  cornua, 

or  part  of  cord,  or  roots  of  anterior  nerves       ...         .8 

4.  Sclerosis       ...........     9 

5.  Myelitis,  recorded  as  diffused,  central,  or  slight  .         .         ,7 

6.  Central  softening  (the  three  most  recent  cases)   ....     3 

7.  Small  clot  in  cord  (Hammond's  case)  .         .         .         .         .1 

8.  Sciatic  neuritis    ..........     1 

It  is  seen  that  the  most  common  lesions  in  these  cases  were  those  of 
inflammation  of  the  spinal  cord,  or  such  as  are  known  to  result  from 
this  inflammation,  to  wit,  atrophy  of  the  nervous  substance  and  sclerosis. 

With  the  data  furnished  by  these  post-mortem  examinations  and  the 
clinical  histories  of  cases,  we  are  the  better  prepared  to  consider  the 
theories  regarding  the  etiology  of  this  malady.  The  views  of  MM. 
lloo-er  and  Damaschino  are  entitled  to  great  consideration,  since  the 
autopsies  which  they  made  were  in  cases  of  shorter  duration,  and  there- 
fore nearer  the  date  of  the  commencement  of  the  paralysis  than  those 
which  have  been  reported  by  other  observers.  Roger  and  Damaschino^ 
published  a  series  of  papers  on  this  malady,  which  they  conclude  with 
the  following  propositions:  "1.  The  alteration  peculiar  to  infantile 
paralysis  is  a  lesion  of  the  spinal  marrow,  which  causes  the  atrophy  of 
muscles  and  nerves.  2.  The  seat  of  this  lesion  is  the  anterior  part  of 
the  gray  substance  of  the  medulla,  where  softened  portions  of  spinal 
substance  are  seen.  3.  This  softening  is  of  an  inflammatory  nature — 
in  fact,  a  simple  myelitis.  4.  Infantile  paralysis  should,  therefore,  be 
called  spinal  paralysis  of  children,  and  be  classed  among  the  affections 
of  the  spinal  marrow,  as  depending  on  myelitis." 

To  determine  the  exact  character  and  limitations  of  the  cause  of 
infantile  paralysis  is  difficult ;  but  the  views  of  Roger  and  Damaschino, 
as  expressed  in  the  above  propositions,  seem  to  harmonize  more  closely 
with,  and  to  aff'ord  a  more  satisfactory  explanation  of,  the  symptoms, 
history,  and  lesions,  thus  far  observed  in  ordinary  or  typical  cases,  than 
does  any  other  theory.  Many  neuropathists  regard  suddenly  occurring 
active  congestion  of  the  anterior  cornua  as  the  cause  of  infantile 
paralysis ;  but  there  is  that  close  affinity  between  active  congestion  and 
inflannnation  that  they  may  be  regarded  as  having  the  same  pathological 
effect  in  this  instance,  and  therefore  the  two  theories  of  a  spinal  conges- 
tion and  spinal  inflammation  may  be  considered  as  one.  It  is  not 
improbable  that  in  some  of  the  cases  which  more  speedily  recover  there 
is  simple  congestion ;  Avhile  in  the  more  obstinate  cases,  and  those  with 
inflammatory  symptoms,  the  congestion  has  passed  into  an  inflamma- 
tion, or  inflammation  was  present  from  the  first.  According  to  this 
theory,  the  atro])hy  so  generally  observed  in  the  twelve  cases  in  which 
autopsies  were  made,  must  be  considered  a  degenerative  change  result- 
ing from  the  inflammation  or  from  the  paralysis.  That  so  accurate  an 
observer  and  so  excellent  a  microscopist  as  Robin  could  detect  nothing 
abnormal  in  the  case  which  he  examined,  was  probably  due  to  the  fact 
that  the  inflammation  or  congestion  abated  without  producing  any 
degenerative  changes  in  the  nervous  substance. 

>  Gaz.  M«l.  de  Pari?,  187In 


ETIOLOGY.  535 

Professor  Charcot  considers  atrophy  of  the  motor  cells  as  the  cause 
of  the  paralysis,  but  it  is  much  more  in  consonance  Avith  the  facts  to 
consider  the  cellular  atrophy  a  result  than  a  cause.  For  how  could 
atrophy,  which  always  occurs  gradualW,  and  by  progressive  increase, 
be  the  cause  of  a  disease  which  begins  abruptly,  and  is  most  intense  in 
the  very  commencement?  Besides,  atrophy  does  not  occur  without 
some  antecedent  disease  to  cause  it. 

In  a  report  to  the  International  Congress  at  Amsterdam,  Drs.  Da- 
maschino  and  Roger  give  the  following  summary  of  the  result  of  their 
recent  study  of  the  pathology  of  infantile  paralysis  •} 

1.  The  anatomical  lesions  are  situated  in  the  motor  regions  of  the 
spinal  cord. 

2.  They  consist  of  a  central  myelitis,  with  a  stadium  of  softening, 
and  atrophic  destruction  of  the  cells  of  the  gray  substance,  together  with 
sclerosis  of  the  lateral  columns,  and  considerable  atrophy  of  the  anterior 
roots  and  the  nerves  leading  to  the  paralyzed  muscles. 

3.  Atrophy  of  the  cells  is  not — as  Charcot  is  of  opinion — the  whole 
process,  as  it  is  in  progressive  muscular  atrophy. 

4.  The  opinion  of  Leyden,  that  there  is  a  circumscribed  and  a  diffuse 
myelitis  in  children,  is  worthy  of  consideration. 

5.  It  remains  for  future  examination  to  decide  whether  the  myelitis 
begins  as  interstitial  or  parenchymatous,  in  the  cellular  tissue  or  the 
nerve-cells. 

It  Avould  be  a  waste  of  time  to  consider  in  full  the  various  theories 
regarding  the  cause  of  infantile  paralysis.  No  one  at  the  present  time, 
of  those  who  are  competent  to  express  an  opinion,  believes  it  to  be  a 
reflex  paralysis,  and  the  expression  dental  paralysis  once  applied  to  it 
is  no  longer  heard.  There  is  one  theory,  however,  which  should 
receive  more  than  a  passing  notice,  and  which  was  earnestly  and  ably 
advocated  by  Barwell,^  of  London,  in  lectures  published  by  him  in 
1872,  to  wit:  "That  this  paralysis  is  purely  peripheral;  a  malady 
affecting  the  ultimate  fibrillne  of  distribution  of  the  nerves  among  the 
muscular  elements.  .  .  .  Its  essence,"  says  he,  "lies  probably  in 
some  subtile  derangement  in  relationship  between  the  ultimate  muscular 
and  terminal  nerve  fibres,  perluvps  from  some  inflamuiatory,  perhaps 
from  some  chemical  or  nutrient  change."  This  theory  has  much  to 
commend  it.  Those  avIio  advocate  it  believe  that  the  atrophy  of  the 
nerves  which  supply  the  paralyzed  limbs  and  of  the  motor  nerve-cell.s 
which  connect  with  the  roots  of  these  nerves  in  the  anterior  cornua 
occurs  in  consequence  of  the  paralysis,  just  as  atrophy  of  tlie  optic  nerve 
can  be  traced  even  into  the  brain  when  the  eye  is  destroyed.  Nor  does 
it  dispose  of  this  tlieory  to  state,  as  has  been  stated,  that  in  order  that 
paralysis  may  occur  in  this  manner,  it  is  necessary  that  there  sliould  be 
the  action  of  a  ])()ison,  analogous  to  wooi-ari,  f  )r  we  ol)serve  sometliin<>' 
similar  to  this  suppf)sed  peripheral  cause  in  facial  paralysis  from  exposure 
to  cold,  in  which  there  can  be  no  poisonous  influence.  This  theory 
therefore  rises  up  most  strongly  in  conflict  with  that  which  attributes 
the  paralysis  to  congestion  or  inflammation  of  the  anterior  cornua,  and 

1  Le  Trogrds  M6dical,  No.  30,  1880.  •'  London  Luncet,  1872. 


530  INFANTILE    PARALYSIS. 

it  is  necessary  to  decide  Ijetwccn  them,  or  to  admit  that  the  paralysis 
mav  sometimes  liavc  one  and  sometimes  tlie  other  cause.  But  the  fact 
that  there  is  in  many  cases  of  infantile  paralysis  a  decided  febrile  move- 
ment and  much  constitutional  disturbance,  Avhen  there  is  no  evidence  of 
any  morbid  action  going  forward  in  the  afiected  limbs  sufficient  to  cause 
these  symptoms,  and  the  fact  that  only  one  set  of  nerves  is  affected, 
to  wit,  the  motor,  which  have  a  distinct  origin  in  the  spine  from  the 
sensitive  nerves,  but  are  intimately  associated  with  them  in  their  distri- 
bution, compoi't  best  with  the  theory  of  a  central  lesion.  Therefore, 
/  he  theory  of  S]iinal  congestion  or  inflammation  appears  the  best  estab- 
lished. Nevertheless,  past  experience  shows  that  medical  theorizers  are 
liable  to  be  too  exclusive,  and  that  in  many  diseases  the  causes  are  not 
uniform,  but  they  vary  in  different  cases,  es))ecially  when,  as  in  the 
present  instance,  the  symptoms  also  vary.  Possibly,  therefore,  there 
may  be  cases  of  paralysis  of  the  extremities  in  children,  especially  those 
.in  which  there  is  little  constitutional  disturbance  and  a  known  exposure 
to  cold,  in  which  the  cause  is  peripheral  instead  of  centric.  The  brain 
;;nd  cerebral  meninges  may  be  excluded  as  sustaining  any  causative 
relation  to  the  paralysis.  There  is  no  symptom  which  indicates  that  they 
are  involved.  The  mind  remains  clear,  and  convulsions  are  no  more 
frequent  than  in  any  other  disease  which  is  attended  by  an  equal  degree 
of  febrile  movement. 

Anatomical  Characters. — All  muscular  fibres  which  are  in  a  state 
of  disuse,  begin  in  a  few  weeks  to  atrophy,  and  undergo  fiitty  degenera- 
tion. The  transverse  strife  in  the  primitive  muscular  fasciculus  gradu- 
ally disappear  and  are  replaced  by  granules  of  f;it,  and  later  still  by 
small  oil-globules.  If  Ave  examine  Avith  the  microsco])e  the  fibres  from 
a  muscle  Avhich  has  been  a  considerable  time  paralyzed,  but  which  has 
still  some  electric  contractility,  we  Avill  find  in  places  the  striae  remain- 
ing, but  numerous  opaque  granules  of  a  fatty  nature  within  the  sarco- 
lemma  wherever  the  strijie  are  absent,  and  in  other  places,  Avhere  the 
degeneration  is  most  advanced,  oil-globules  occur,  always  small.  If  the 
paralysis  be  more  profound,  the  striffi  have  all  disappeared.  At  a  later 
stage,  usually  after  some  years  in  cases  of  complete  and  incurable  paral- 
ysis, the  fatty  matter  may  be  to  a  considerable  extent  absorbed,  and 
the  fibrous  netAvork  of  the  muscle  which  remains  presents  a  tendinous 
appearance.  There  is  a  great  difference,  hoAvever,  in  different  cases,  as 
regards  the  rapidity  Avith  Avhich  these  changes  occur.  Hammond  states 
that  he  found  the  stri;^  remaining  in  tAvo  cases  after  the  la])sc  of  more 
than  four  years  of  decided  paralysis.  The  nerves  of  the  paralyzed  part 
also  undergo  atrophy. 

Diagnosis. — This  is  easy  as  soon  as  the  attention  of  the  physician  is 
directed  to  the  state  of  the  limbs.  In  a  large  proportion  of  cases  the 
mother  or  nurse  first  observes  the  paralysis,  and  calls  the  attention  of 
the  ])hysician  to  it.  A  knoAvledge  and  recollection  of  the  facts  in  rela- 
tion to  infantile  paralysis  should  lead  the  ])liysician  to  examine  the  state 
of  the  limbs  in  all  cases  of  marked  febrile  excitement  in  young  children, 
occurring  Avithout  apparent  cause. 

Prognosl'^. — It  may  be  confidently  predicted,  if  the  child  be  seen 
early,  and  correctly  treated,  that  the  paralysis  Avill  diminish,  if  it  can- 


TREATMENT.  537 

not  be  entirely  cured.  If  the  paralysis  have  continued  a  considerable 
time,  and  there  be  no  electric  contractility  of  the  muscles,  there  is  poor 
prospect  of  any  improvement.  The  induced  current  will  fail,  sometimes, 
to  cause  muscular  contraction,  when  the  direct  current  may  produce  it; 
but  if  there  be  no  response  to  the  direct  current,  there  is  no  tlierapeutic 
agent  which  can  restore  the  use  of  the  limb. 

In  cases  seen  soon  after  tlie  paralysis  commences,  and  before  the  stage 
of  atrophy,  the  prognosis  is  most  favorable,  when  there  is  still  slight 
voluntary  motion,  and  improvement  commences  eai'ly.  In  most  in- 
stances, even  when  the  paralysis  has  been  mild,  and  of  comparatively 
short  duration,  the  limb,  although  its  motion  be  fully  restored,  is  for  a 
long  time  weaker  than  the  limb  on  the  opposite  side. 

Treatment. — A  physician  called  at  the  commencement  of  the  paral- 
ysis should  endeavor  to  remove  every  cause  which  might  increase  the 
irritability  of  the  nervous  system.  Some  advise  to  scarify  the  gums,  if 
much  swollen  and  tender  from  dentition,  the  bowels  should  be  kept_ 
regular,  worms,  if  present,  expelled  by  appropriate  medicines,  and  the 
diet  be  plain  and  unirritating.  Since  the  cause  of  the  paralysis  is,  in 
the  commencement,  still  operative,  measures  are  appropriate  which  are 
calculated  to  remove  it. 

Local  treatment  is  very  important  at  all  periods  of  the  paralysis.  In 
the  first  days  cold  applications,  as  by  an  India-rubber  bag  containing  ice, 
should  be  made  over  the  spine.  Stimulating  embrocations  over  the 
spine,  and  upon  the  paralyzed  limb,  are  appropriate  after  the  cold  has 
been  discontinued,  and  benefit  may  also  be  derived  from  dry  cups  alone; 
the  spine.  Ergot,  the  bromide  and  iodide  of  potassium,  which  may  be 
administered  variously  combinccl,  or  singly,  are  the  appropriate  remedies 
for  the  first  twelve  or  fourteen  days.  Administered  every  three  or  four 
lioiirs  ill  proper  dose,  they  are  the  most  effectual  of  all  internal  remedies 
for  diuiinishing  spinal  congestion,  and  preventing  effusion,  and  perma- 
nent structural  change  in  the  cord.  Unfortunately  this  first  stage  is  in 
many  instances  far  advanced  before  proper  treatment  is  employed  to 
subdue  the  myelitis,  either  from  an  incorrect  diagnosis,  or  because  the 
physician  is  not  summoned  until  structural  changes  have  occurred, 
which  constitute  the  second  stage. 

If  the  paralysis  continue,  or  if  it  do  not  progressively  diminish,  we 
should  not  delay  more  than  two  weeks  from  the  connnencemeut  of  the 
disease  before  employing  ap]u-opriate  measures  to  restore  the  use  of  the 
limbs,  and  arrest  atrophy  of  the  muscles.  The  expectant  jdan  of  treat- 
ment which  is  proper  in  many  diseases  of  children  is  unsuited  to  this. 
Muscular  atrophy  may  commence  in  three  weeks,  and  the  further  it  has 
:idv:inced,  the  more  difficult  and  tedious  will  be  the  cure.  Therefore, 
by  the  close  of  the  .second  week  if  the  paralysis  continue,  or  be  not 
rapidly  disappearing,  iron  as  a  tonic  with  strychnia  should  be  pre- 
scribed. There  is  probably  no  better  formula  f>r  the  exhihition  of 
these  agents  than  the  f)llowing  from  Professor  llammoml: 

li . — Strvch,  iiul|ihHt.  .         .         .         .         .         .  pr  j. 

Ferri  pyro|ihosphat    .         .         .         .         .         .  j'*'- 

Acidi  pliiisphorici  dil  it.     .....  2'"'- 

iSyr.  zingib S'U'-s:. — Misce- 


538  FACIAL    PARALYSIS. 

Onc-tliird  of  a  teaspoonful,  or  one-ninetieth  of  a  grain  of  strychnia, 
is  sufficient  for  a  child  of  two  years,  administei-ed  three  times  daily. 
Hillier,  liarwell,  and  others  have  employed  subcutaneous  injections 'of 
strychnia,  with,  it  is  stated,  a  good  result.  While  in  the  first  and 
second  weeks  the  child  has  been  allowed  to  remain  quiet,  he  should  now 
be  encouraged  to  use  his  limbs.  Frec^uent  muscular  contraction  must, 
if  possible,  be  produced,  and  the  voluntary  movements,  when  not  totally 
lost,  aid  greatly  in  promoting  the  nutrition  of  the  muscles  and  restoring 
their  function.  Immersing  the  limb  for  half  an  hour  in  water  at  a  tem- 
perature of  110  or  115  degrees,  rubbing  the  limb  Avith  a  coarse  towel, 
and  kneading  the  muscles,  aid  also  in  restoring  nutrition  and  tone  to 
them. 

But,  fortunately,  we  have  an  invaluable  agent  in  the  subtle  electrical 
fluid,  which  can  be  made  to  penetrate  the  muscles  and  cause  their  con- 
traction when  every  other  measure  has  failed.  The  induced  current 
should  be  employed  upon  the  limb  every  day,  or  second  day,  if  it  cause 
the  muscles  to  act,  but  if  the  loss  of  power  be  of  long  standing,  or  com- 
plete, so  that  the  induced  current  is  not  sufficiently  powerful,  the  direct 
current  should  be  used  instead.  It  is  not  regarded  as  important  which 
way  the  current  passes,  provided  that  the  muscles  contract. 

In  a  large  proportion  of  cases  a  cure  cannot  be  effected  until  the 
lapse  of  several  months,  so  that  the  patience  of  the  physician  and 
friends  may  be  put  to  the  test ;  but  if  muscular  atrophy  can  be  pre- 
vented, and  the  limb  kept  at  nearly  the  normal  temperature,  this  mode 
of  treatment  will  ordinarily  in  the  end  be  successful.  The  primary  affec- 
tion Avhich  caused  the  paralysis  will,  with  some  exceptions,  be  removed 
by  the  treatment  indicated  above,  after  Avhich  the  state  of  the  muscles 
and  their  nervous  supply  demand  the  whole  attention.  Observations 
show  that  by  treatment  perseveringly  employed,  fatty  degeneration  of 
the  muscular  fibres  can  be  not  only  arrested,  but  the  ftxt  which  has 
already  been  deposited  within  the  sarcolemma  may  be  absorbed,  and  the 
muscular  strige  restored.  In  those  cases  in  which  it  has  been  necessary 
to  employ  the  direct  current,  the  induced  should  be  used,  whenever  by 
the  improvement  of  the  case  it  is  found  sufficiently  powerful. 


CHAPTEK  XYI. 

FACIAL  PARALYSIS. 

Causes. — Facial  paralysis,  in  the  newborn,  commonly  occurs  from 
pressure  of  the  blade  of  the  forceps  uj)on  the  portio  dura,  at  a  point 
external  to  the  stylo-mastoid  foramen.  It  may  also  occur  in  children  of 
any  age,  from  exj)osure  of  the  face  to  a  cold  wind.  The  pressure  of  a 
tumor  upon  some  part  of  the  portio  dura,  or  even  of  the  fist  of  the  child 


TREATMENT.  539 

placed  under  the  face  during  sleep,  may  cause  it.  It  may  also  result 
from  disease  of  the  temporal  bone,  producing  pressure  on  the  nerve, 
as  caries,  periostitis,  suppuration,  or  hemorrhage  into  the  aqu«ductus 
Fallopii,  and  also  from  intracranial  disease  aflecting  the  pons  Varolii 
or  tlie  medulla  oblongata. 

Symptoms. — The  portio  dui-a,  which  is  a  nerve  of  motion,  supplies 
the  muscles  of  the  face,  and  therefore  its  loss  of  function  is  at  once  mani- 
fest in  distortion  of  the  features.  The  eye  of  the  affected  side  remains 
open  in  consequence  of  paralysis  of  the  orbicularis  palpebrarum,  the 
upper  lid  being  raised  by  the  levator  muscle,  which  is  not  paralyzed,  since 
its  nerve  is  derived  from  the  third  pair.  From  the  inability  to  Avink, 
the  eye  becomes  irritated  by  dust  and  constant  exposure,  and,  in  chil- 
dren old  enough  to  have  an  abundant  lachrymal  secretion,  the  tears  are 
liable  to  flow  over  the  cheek.  On  account  of  the  paralyzed  and  relaxed 
state  of  the  facial  muscles  the  mouth  is  drawn  toward  the  healthy  side, 
while  the  affected  side  presents  a  swollen  appearance.  Movement  of  the 
eyebrow  of  the  anterior  portion  of  the  scalp  on  the  paralyzed  side  is  also 
impossible,  since  the  occipito-frontalis  and  corrugator  supercilii  are  sup- 
plied by  the  portio  dura.  If  the  cause  of  the  disease  be  located  above 
the  origin  of  the  chorda  tympani,  the  flow  of  saliva  and  sense  of  taste 
on  the  affected  side  are  impaired.  If  the  injury  be  posterior  to  the 
gangliform  enlargement,  those  symptoms  are  superadded  which  are  due 
to  paialysis  of  the  petrosal  nerves. 

The  accompanying  woodcut  represents  a  case  which  was  under  obser- 
vation in  the  New  York  Infant  Asylum.  It^  age  at  admission  Avas 
about  five  months,  and  its  previous  history  Avas  unknoAvn.  The  paral- 
ysis Avas  ])ermanent.  Death  occurred  some  months  later  from  an  inter- 
current disease,  and  no  cause  of  the  paralysis  could  be  discovered  in  a 
careful  examination. 

Progxosis. — This  depends  on  the  cause.      If  the  cause  be  periph- 
eral, as  from  the  pressure  of  the  forceps  or  from  cold,  the  prognosis 
is  favorable.      In  cases  of  deep-seated  le- 
sion, uidess  syphilitic,  the   prognosis  is  ^lo-  31. 
usually  unfavorable.     A  syphilitic  lesion 
can    often    be    removed   by    a])])ropriate 
remedies,  and  the  paralysis  cured. 

Treatment. — In  the  paralysis  of  the 
newborn,  from  pressure  of  the  forceps, 
all  that  is  ref[uired  is  occasional  rubbing 
or  gentle  kneading  over  the  affected 
nmscles.  In  those  Avho  are  older,  the 
nature  of  the  cause,  so  far  as  ascertained,  V\\.\V  f  " 

must  determine  the  treatment.      If  there        C  ^^"/i  ^^»*'/'j  // 
be    glandular    sAvellings,    and    discharge       '^»^->  y- — '   r  > 
from   the  ear  from  scrofula,  cod-liver  oil 
and   the  syrup  of  the  iodide  of  iron  are 

re()uiied  internally,  Avitli  appropriate  external  treatment  of  the  glands 
and  ear.  If  syphilis  be  the  cause,  mercurials  and  the  iodide  of  potas- 
sium should  be  employed.  If  the  patient  do  not  soon  begin  to  im- 
yrove,   the    treatment    recommended  for    infantile    paralysis,  modified 


O40  PARALYSIS    AVITII    PSEU  DO  -  II YT  E  ET  RO  P  II Y  . 

somc^vllat  on  account  of  tlic  difference  in  location,  is  appropriate.  Iron 
and  strychnia  may  be  administered  internally.  The  external  treatment 
should  consist  of  friction,  kneading,  hot  applications,  and  the  electric 
current.  The  current  should  have  oidy  moderate  intensity,  for  a  high 
degree  of  it  might  injure  the  vision.  It  should  bo  applied  every  second 
day,  with  one  pole  over  the  mastoid  foramen,  and  the  other  moved  slowly 
over  the  muscles. 


Paralysis  -with  Pseudo-Hypertrophy. 

This  is  a  rare  disease.  It  was  first  described  by  Duchenne  in  18G1, 
and  since  the  attention  of  the  profession  was  directed  to  it,  cases  have 
been  observed  on  the  Continent,  in  Great  Britain,  and  in  tliis  country. 
Though  our  acquaintance  with  it  is  so  recent,  it  has  been  fully  and  ac- 
curately described  by  various  "writers  in  our  language.  The  Trans- 
actions of  the  London  Patliological  Society  for  18G8,  contain  a  trans- 
lated paper  relating  to  it,  communicated  by  INI.  Duchenne,  with  photo- 
graphic views  and  remarks  by  Lockhart  Clarke,  and  also  the  histories 
of  two  cases  occurring  in  London,  and  exhibited  to  the  Society  by  Adams 
and  Hillier.  In  this  country  an  elaborate  paper  has  appeared  on  this 
form  of  paralysis,  from  the  pen  of  Dr.  Webber,^  of  Boston,  wdio  suc- 
ceeded in  collecting  the  records  of  forty-one  cases  ;  and  more  recently 
Dr.  Poorc,'  physician  to  the  New  York  Charity  Hospital,  collated  the 
records  of  eighty-five  cases,  which  furnish  the  material  of  an  excellent 
monograph. 

Weakness  of  the  legs,  and  a  peculiar  waddling  gait,  are  the  first  ob- 
servable symptoms,  and  by  them  we  are  able  to  ascertain  approximately 
the  date  of  the  commencement  of  the  paralysis.  In  27  of  the  cases  col- 
lated by  Dr.  Poore,  the  malady  began  so  early  in  infancy  that  they 
were  never  able  to  walk  like  other  children  ;  in  5  there  is  no  record  in 
regard  to  the  time  wdien  the  peculiar  gait  was  first  observed,  or  whether 
they  ever  could  walk.  Fifty-two,  or  about  two-thirds  of  the  cases, 
walked  well  at  first,  having  no  symptoms  of  the  paralysis  till  after  the 
age  of  two  years.  In  15  of  these,  Aveakness  of  the  legs  and  the  peculiar 
gait  were  first  observed  between  the  ages  of  two  and  a  half  and  five 
years ;  in  23  between  the  ages  of  five  and  ten  years  ;  in  6  between  the 
ages  of  ten  and  sixteen  years,  and  in  8  over  the  age  of  sixteen  years. 
It  is  seen,  therefore,  that  this  malady  is  preeminently  one  of  infancy 
and  childhood. 

The  gait,  which  is  unsteady  and  waddling,  has  been  compared  to  that 
of  a  duck.  The  child,  stands  with  the  legs  wide  apart,  aiid  from  the 
weakness  of  the  legs,  and  unsteadiness  of  the  gait,  frequently  stund>les 
and  falls.  In  many  cases  this  nniscular  Aveakness  and  difficulty  in 
walking  occur  before  there  is  any  perceptible  enlargement  of  the  mus- 
cles beyond  the  normal  size. 

The  hypertrophy  occurs  without  tenderness,  pain,  or  other  nervous 
Bymptoms,  and  without  fever  or  constitutional  disturbance.      Occasion- 

1  Boston  Med.  and  Siir<r.  Journ.,  Nov.  17,  1870. 
'  Isfew  York  Medical  Jonraal  for  June,  1875. 


PARALYSIS    WITH    PSEU  DO  -  H  YP  E  RTROP  H  Y 


o41 


Fio.  32. 


ally  tho  patient  complains  of  stiffness  or  aching  in  the  limbs,  especially 
after  exercise,  even  before  the  enlargement  is  observed,  and  exception- 
ally there  is  pain,  even  acute,  in  the  legs.  The  hypertrophy  is  ordi- 
narily observed  first  in  the  calf  of  one  leg,  and  then  in  the  opposite  calf. 
In  a  case  related  by  Niemeyer,  the  muscles  of  the  gluteal  region  were  first 
affected.  In  nearly  all  cases  the  gastrocnemii  are  hypertrophied.  Q'here 
were  only  two  exceptions  in  the  85  cases  collated  by  Dr.  Poore ;  but 
ahoost  any  of  the  other  muscles,  or  groups  of  muscles,  may  also  be  in- 
volved. The  muscles  which  are  most  prominently  affected,  and  which 
produce  the  characteristic  deformities,  are  those  of  the  extremities  and 
posterior  aspect  of  the  trunk.  Spinal  curvature,  Avhich  is  attributed  to 
the  weakened  state  of  the  erector  muscles  of  the  spine,  appears  early, 
and  is  seldom  absent.  The  bending  is  such  that  a  pluml)-line,  falling 
from  the  most  posterior  of  the  spinous  processes,  falls  behind  the  plane 
of  the  sacrum,  which  is  a  means  of  distinguishing  this  disease  from  cer- 
tain other  spinal  affections.  The  woodcut  represents  a  case  which  came 
to  the  children's  class  at  Bellevue,  in  April,  1872.  The  boy  was  two 
years  old,  and  the  mother  stated  that  the  peculiar  gait  an<l  the  enlarge- 
ments had  only  been  observed  from  four  to  six  weeks,  and  yet  the  curva- 
ture of  the  spine  was  quite  marked.  He  did  not  return  to  the  class,  and 
his  subsequent  history  is  therefore  unknown. 

Of  the  muscles  in  the  upper  extremities  the  deltoid  and  scapular  are 
the  most  frefpiontly  enlarged.  Hypertrophy  of  the  temporals  has  been 
observed  in  tliree  cases,  of  the  masseters  in 
two,  of  tlie  tongue  in  three,  and  of  the  heart 
in  four  (Poore). 

We  shall  see  presently  that  atrophy  oc- 
curs in  tlie  muscular  clement  of  the  ])arts 
which  arc  affected,  and  that  the  hypertropliy 
is  due  to  hyperplasia  of  the  connective  tissue. 
Now  occasionally  this  hyperplasia  does  not 
occur  or  is  tardy  in  occurring,  Avhilc  the 
atrophy  has  taken  place.  Therefore,  certain 
muscles  may  have  less  than  the  normal  vol- 
ume, which,  from  contrast  with  those  which 
are  hy[)erti*ophied,  increases  the  deformed 
appearance.  In  ordinary  cases  the  enlarge- 
ment advances  more  rapidly  and  continues 
greater  in  the  gastrocnemii,  which  are,  as  we 
have  stated,  the  muscles  first  affected,  than 
in  other  muscles,  and  therefore  tlicre  are  more 
])rominence  and  hardness  of  the  calves  of  the 
legs  than  elsewhere.  In  advanced  cases  walk- 
ing is  impossible,  and  the  patient  is  obliged 

to  remain  in  a  reclining  posture.  Sometimes  from  tho  uncrpial  muscidar 
action  the  feet  become  extended  and  the  toes  flexed,  so  that  the  clnld,  in 
attempting  to  walk,  steps  on  the  anterior  part  of  the  sole  of  the  foot,  as 
in  talipes  equinus. 

In  the  first  stages  of  the  disease  the  electric  contractility  of  the  mus- 
cles is  nearly  normal,  but  in  advanced  cases  response  to  the  galvanic 


542  PARALYSIS    TTITII    PSE  U  DO -H  Y  P  ERT  R  O  P  H  Y  , 

current  becomes  more  and  more  feeble,  according  to  the  degree  of 
atrophy  of  tlie  muscular  fibres.  The  skin  retains  its  normal  sensibility, 
■with  exceptional  instances  in  Avhich  there  is  numbness  either  general  or 
in  places.  Reddish  or  bluish  mottling  of  the  surface  of  the  extremities 
is  sometimes  observed,  which  is  attributed  by  some  to  obstructed  venous 
circulation  in  the  hypertrophied  muscles,  and  by  others  is  supposed  lo 
be  due  to  the  peculiar  neurop;'thic  state.  The  bladder  and  rectum  are 
not  involved.  The  mental  faculties  are  more  or  less  blunted  and  feeble 
in  certain  cases,  especially  in  those  which  commence  in  early  infancji, 
but  in  some  patients  they  do  not  seem  to  be  materially  impaired. 

Anatomical  Characters. — There  have  been  so  few  post-mortem 
examinations  of  those  who  died  having  this  disease,  that  it  is  still  uncer- 
tain whether  there  is  any  centric  lesion.  Cobnheim  examined  the  spinal 
cord  in  one  case,  and  could  find  nothing  al)normal.  Recently,  JNIr. 
Kesteven  has  examined  the  brain  and  spinal  cord  from  a  case,  and  found 
dilatation  of  the  perivascular  canals,  both  in  the  brain  and  spinal  cord, 
and  also  spots  of  granular  degeneration  chiefly  in  the  white  substance, 
"caused  by  loss  of  cerebral  tissue  replaced  by  morbid  matter."'  As 
this  child  was  imbecile,  it  is  not  improbable  that  these  lesions  were  con- 
nected with  the  mental  state,  and  not  the  muscular  disease. 

Professor  Charcot^  reports  a  careful  microscopic  examination  of  the 
spinal  cord  and  of  the  nerves  in  a  case  Avhich  had  continued  ten  years. 
He  could  discover  no  deviation  from  the  healthy  state.  More  recently 
Dr.  J.  Lockhart  Clarke^  examined  a  case  and  found  the  encephalon 
healthy,  but  in  the  spinal  cord  there  was  more  or  less  disintegration  of 
the  gray  substance  in  each  lateral  half,  and  in  places  dilatation  of 
vessels,  and  commencing  sclerosis. 

It  seems,  therefore,  that  central  lesions  are  not  essential,  and  are 
sometimes  absent.  When  they  do  occur,  it  is  probable  that  they  are 
consecutive  to  the  paralysis. 

The  essentinl  lesions  in  this  malady  are  atrophy  of  muscular  fibres 
and  hyperplasia  of  the  connective  tissue  which  surrounds  these  fibres. 
The  hyperj)lasia  of  the  one  element  in  the  muscle  is  greater  tban  the 
atrophy  of  the  other,  and  hence  the  increase  of  volume  above  the  normal 
size.  The  atrophy  is  probably  a  primary  lesion,  for  muscular  weakness 
ordinarily  occurs  for  a  considerable  time  before  there  is  any  evidence  of 
the  enlargement,  an*^!,  as  we  have  seen,  certain  muscles  may  undergo 
the  atrophy  without  the  hyperplasia.  Still  the  mechanical  effect  of  the 
newly  formed  connective  tissue,  doubtless,  increases  the  atrophy  in  those 
muscular  fibres  which  this  tissue  surrounds,  and  the  comparatively  quiet 
state  of  muscles  in  consequence  of  paralysis  not  only  tends  to  promote 
the  atrophy  and  degeneration  of  these  muscles,  but  also  of  contiguous 
healthy  muscles. 

The  muscles  which  are  involved  in  this  paralysis  present  a  pale  yel- 
lowish hue,  resembling,  says  Niemeyer,  the  appearance  of  lipoma.  Ex- 
amining by  the  microscope,  we  find  in  addition  to  a  large  increase  in 
the  fibrous  tissue  and  atrophy,  and  in  some  places  disappearance  of  the 

1  .Jour,  of  M<'<].  8ci.,  Jan.  ]871. 

2  Arcliiv.  do.  Physiol  ,  March,  1872. 
»  Medico-Chir.  trans.,  1874. 


TREATMENT,  643 

muscular  element,  more  or  less  fatty  matter,  granular  and  globular,  oc- 
cupying the  interstices.  Mr.  Kesteven  describes  as  follows  the  appear- 
ance of  the  muscles  in  the  case  which  he  examined:  "The  muscular 
substance  is  pale,  almost  white,  and  very  greasy.  The  superabundance 
of  fat  is  evident  to  the  naked  eye.  The  muscular  fibres  present  the 
ordinary  striation,  but  less  distinctly  than  usual.  The  ultimate  fibres 
are  pale,  and  separated  by  a  large  increase  of  areolar  and  fibrous  tissue." 

Causes. — Why  there  is  this  strange  perversion  of  nutrition,  so  that 
there  is  an  exaggerated  development  of  the  connective  tissue  of  the 
muscles  and  atrophy  of  the  muscular  fibres,  is  unknown.  Boys  are 
more  liable  to  be  affected  than  girls.  Of  the  eighty-five  cases  embraced 
in  the  statistics  of  Dr.  Poore,  seventy-three  were  boys,  and  there  was  a 
similar  excess  of  males  in  the  cases  collated  by  Dr.  Webber. 

There  is  in  a  considerable  proportion  of  cases  the  record  of  heredi- 
tary transmission,  and  in  almost  all  the  instances  the  predisposition  is 
acquired  from  the  mother's  side.  Thus  in  thirty-seven  of  Dr.  Poore's 
cases  "two  or  more  belonged  to  the  same  family."  In  some  instances 
three  and  even  four  maternal  relatives  had  this  form  of  paralysis.  In 
one  case  observed  by  Duchenne,  and  in  a  few  others  subsequently  ob- 
served, this  malady  seemed  to  be  congenital,  for  the  limbs  at  birth  were 
unusually  large,  and  the  patients,  when  they  came  under  observation, 
were  unable  to  walk.  No  relation  has  been  observed  between  this 
paralysis  and  syphilis,  scrofula,  or  other  diathesic  diseases. 

Prognosis. — This  disease  is  in  most  instances  progressive,  termi- 
nating fatally  after  a  variable  period.  It  is  in<its  nature  chronic,  rarely 
ending  in  less  than  five  or  six  years.  A  considerable  proportion  live 
longer,  some  even  attaining  adult  age.  The  paralysis  may  be  stationary 
for  a  time,  but  afterward  continue  to  increase.  Duchenne  has  reported 
one  case  of  recovery.  In  two  or  three  other  instances  patients  ap- 
peared to  improve  somewhat  under  treatment,  but  the  Avriters  admit 
they  may  have  become  worse  afterward.  Death  usually  occurs,  not 
directly  from  the  paralysis,  but  from  some  intercurrent  disease,  especi- 
ally of  the  lungs. 

Treatment. — The  treatment  thus  far  employed  has  been  chiefly 
local,  consisting  in  the  use  of  electricity,  and  kneading  or  shampooing 
over  the  affected  muscles.  Both  the  primary  and  induced  electrical 
currents  have  been  employed,  but.  unfortunately,  without  any  appre- 
ciable benefit  in  most  cases.  Benedikt,  who  claims  a  better  result  from 
electrization  than  any  other  observer,  applied  the  copper  pole  over  the 
lower  cervical  ganglion,  and  the  zinc  pole  along  the  side  of  the  lumbar 
vertebrie  by  means  of  a  broad  metallic  plate. 


>4:-i  DISEASES    OF    SPINAL    CORD,  ETC. 


CHAPTER  XYII. 

DISEASES  OF  THE  SPINAL  CORD  AND  ITS  COVEEINGS. 

The  diseases  of  the  spinal  cord,  and  of  the  parts  -wliicli  cover  and 
protect  it,  are  important,  but  they  are  less  understood  tliaii  are  those 
of  any  other  portions  of  the  body.  This  is  partly  due  to  the  fact,  that 
in  many  cases  the  spinal  disease  coexists  with  a  similar  pathological 
state  of  the  brain  or  its  meninges,  the  symptoms  of  Avliich  predominate 
and  mask  those  which  pertain  to  the  spine,  partly  to  the  fact  that  the 
chief  symptoms  of  spinal  disease  are  often  located  in  organs  or  parts 
which  are  at  a  distance  from  the  soine,  and,  lastly,  to  the  fact  that  it  is 
difficult,  for  obvious  physical  reasons,  to  determine  the  exact  state  of  the 
spine  at  the  bedside;  while  post-mortem  inspection  of  the  spine,  Avhich 
alone  can  give  accurate  pathological  knowledge,  is  less  frec^uently  made 
than  of  any  other  organ. 

Certain  spinal  diseases  occurring  in  childhood  are  the  same  as  in 
adult  life,  presenting  identical  symptoms  and  lesions  in  the  two  periods, 
and  therefore  they  require  no  extended  notice  in  this  treatise.  Others 
are  common  to  childhood  and  maturity,  but  they  present  peculiarities 
in  the  former  period  which  require  to  be  pointed  out,  while  others  still 
are  peculiar  to  childhood. 

Spinal  irritation  is  not  infrequent  in  delicate  and  poorly  fed  children. 
I  have  from  time  to  time  observed  marked  cases  of  it  in  the  class  in  the 
Outdoor  Department  of  Bellevue,  the  patients  usually  being  above  the 
age  of  three  or  four  years,  and  exhibiting  evidences  of  cachexia.  Most 
of  them  have  been  spare  and  pallid,  some  affected  with  a  nervous 
cough  or  palpitation,  and  some  with  neuralgic  pains  in  the  chest,  abdo- 
men, or  elsewhere,  which  pressure  at  a  certain  point  upon  the  spine 
intensified.  These  cases  recover  by  better  feeding,  outdoor  exercise, 
mild  counter-irritation  along  the  spine,  and  the  use  of  tonics,  especially 
of  iron. 

Primary  inflammation  of  the  cord  and  its  meninges  is  rare  in  chil- 
dren. Secondary  inflammation  of  these  parts  is,  on  the  other  hand, 
more  common  in  children  than  in  adults.  It  is  common  in  caries  of 
the  vertebrae,  and  in  cerebro-spinal  fever.  The  i)reponderance  in  func- 
tional activity  of  the  spinal  cord,  and  the  feeble  controlling  power  of 
the  brain,  render  childhood  more  liable  to  convulsions  and  reflex  paral- 
ysis than  any  other  period  of  life.  Until  within  a  recent  period,  most 
cases  of  infantile  paralysis  Avere  believed  to  be  reflex,  due  to  dentition, 
intestinal  irritation,  etc.,  but  it  is  now  attributed  to  myelitis  in  the 
motor  region  of  the  spinal  cord  (see  remarks  in  article.  Infantile  Paral- 
ysis). Still  there  are  cases  of  true  reflex  paralysis  in  children,  in  regard 
to  the  etiology  of  which  there  can  be  no  doubt.  Prof.  Sayre,  of  this 
city,  has  called  attention  to  the  fact,  that  balanitis  and  preputial  udhe- 


CONGESTION    OF    SPINAL    CORD,  ETC.  5-io 

sions  sometimes  cause  paraplegia,  more  or  less  pronounced,  in  young 
children,  and  which  is  relieved  by  dividing  the  adhesions,  and  restoring 
the  mucous  surface  of  the  glans  and  prepuce  to  its  normal  state.  Such 
a  case  was  brought  to  the  children's  class  in  the  Outdoor  Department 
at  Bellevue,  in  April,  1875.  The  child  could  not  walk,  or  scarcely 
stand,  without  support,  but  after  the  division  of  the  adhesions,  and  sub- 
sidence of  the  inflammation,  locomotion  rapidly  improved.^  It  is  well 
known  that  masturbation  sometimes  causes  a  similar  weakness  of  the 
lower  extremities.  Dr.  West  relates  the  case  of  a  child  "  between  two 
and  three  years  old,"  who  began  to  totter  in  his  gait,  and  finally  almost 
ceased  walking.  He  was  observed  to  practise  masturbation.  "  This 
was  put  a  stop  to,"  and  he  soon  recovered  his  health  and  his  power  of 
locomotion." 


Congestion  of  the  Spinal  Cord  and  its  Membrane. 

Congestion  of  the  spinal  cord  and  meninges  occurs  both  as  a  primary 
and  secondary  malady,  the  latter  being  more  frequent  than  the  former. 
It  may  be  active  or  passive.  Active  congestion,  occurring  indepen- 
dently of  meningitis  or  myelitis,  is  in  most  instances  transient,  and  sub- 
ordinate to  some  graver  disease,  in  the  course  of  which  it  arises.  It  is 
probably  often  overlooked.  It  is  not  fatal,  and  its  symptoms  are  fre- 
quently masked  by  those  which  are  referable  to  the  brain  or  some  other 
organ.  It  is  believed  to  be  common  in  the  initial  period  of  certain  of  the 
fevers  of  childhood.  It  is  not  improbable  that'  the  hvperiesthesia  ob- 
served upon  the  thoracic  and  abdominal  surfiices  and  along  the  thighs, 
in  the  commencement  of  remittent  and  certain  other  febrile  diseases, 
has  its  origin  in  a  congested  state  of  the  spine.  To  this  congestion 
writers  attribute  the  lumbar  pain  and  occasional  paraplegia  in  the  initial 
stage  of  variola.  Active  spinal  congestion  may  also  result  from  the 
sudden  impression  of  cold,  and  to  it,  as  has  been  stated  above,  most 
neuropathists  attribute  the  so  called  infantile  paralysis  or  poliomyelitis 
acuta. 

Certain  anatomical  circumstances  favor  the  occurrence  of  passive  con- 
gestion of  the  spinal  cord  and  meninges,  to  wit,  the  tortuousness  of  their 
veins,  and  the  absence  of  valves  in  these  veins,  the  lack  of  muscular 
support  of  tlie  vessels,  and  the  inferior  position  of  the  si)ine  in  sickness 
as  the  patient  lies  quietly  in  Ijcd.  A  common  cause  of  ])assive  conges- 
tion of  these  parts  is  s(mie  protracted  and  enfeebling  disease,  which 
diminishes  the  contractile  force  of  the  heart  (cardiac  paresis),  producing 
congestion  of  the  spinal  cord  in  the  same  manner  as  under  similar  cir- 
cumstances hypostatic  congestion  of  the  lungs  occurs.  Severe  convul- 
sive diseases,  as  tetanus  or  eclampsia,  when  protracted  or  occurring  at 
short  intervals,  commonly  produce  spinal  congestion.     In  tetanus,  this 

'  Some  months  fince  I  requested  Drs.  Iloliiftte  airl  Boslev,  attendin;;  phv-ician-i 
in  the  children's  cla<.s  at  Bfllovno,  to  mai<o  examination  of  tlu!  state  of  thu  picpiicn 
in  infancy.  They  report  that  they  have  found  prc|nitial  adhesions  almost,  daily,  in 
most  instances  without  symptoms,  but  sometimes  with  dy.suria,  and  only  in  rare 
instances  with  paralysis. 

^  Diseases  of  Children,  page  14G,  4th  American  edition. 

86 


546  CONGESTIOX    OF    SPIKAL    CORD,  ETC. 

congestion  is  extreme,  so  that  extravasation  of  blood  is  liable  to  occur 
from  the  engorged  vessels,  especially  those  of  the  pia  mater. 

Anatomical  Characters. — It  is  often  impossible,  at  post-mortem 
examinations,  to  determine  how  much  of  the  congestion  of  the  spine  and 
its  meninges  is  pathological,  and  how  much  cadaveric ;  since,  if  the 
corpse  be  placed  on  its  back  at  death,  a  very  considerable  engorgement 
of  the  spinal  vessels  occurs  from  gravitation  of  blood.  If  the  body  have 
been  placed  on  the  side  or  face,  this  cadaveric  congestion  is  prevented. 
Since,  in  active  congestion,  the  arterioles  and  capillaries  are  distended 
with  arterial  blood,  the  color  is  a  brighter  red  than  in  passive  conges- 
tion, in  which  venous  blood  predominates.  Active  congestion  of  the 
cord  usually  coexists  with  that  of  the  meninges,  but  it  may  occur  w'th- 
out  it.  In  cases  of  considerable  congestion,  the  "  puncta  vascuh  sa" 
appear  upon  the  incised  surface,  both  of  the  white  and  gray  substince. 
If  the  congestion  be  protracted,  or  if  it  recur  frequently,  it  may  produce 
permanent  dilatation  of  the  arterioles  and  capillaries,  in  greater  or  less 
degree,  and  it  may  also  lead  to  sclerosis  of  the  cord.  Passive  conges- 
tion seldom,  perhaps  never,  occurs  in  tiie  cord,  without  being  equally 
and  often  to  a  greater  extent  present  in  the  meninges.  Continuing  for 
a  time  it  gives  rise  to  transudation  of  serum  into  the  interspaces  over 
the  cord,  and  even  softening  of  the  cord  may  occur  to  a  limited  extent 
from  imbibition  of  serum.  In  cither  form  of  congestion,  extravasations 
of  blood  are  frequent. 

Symptoms. — Spinal  congestion  is  announced  by  pain  in  the  region 
of  the  spine,  usually  in  the  lumbar,  or  dorsal  and  lumbar  portions,  and 
irradiations  of  pain,  and  tingling  in  the  legs.  In  addition,  more  or  less 
paralysis  of  the  bladder  and  legs  may  result.  The  paraplegia  may 
occur  early  or  not  till  the  lapse  of  several  days.  In  active  congestion, 
the  symptoms  are  rapidly  developed,  and  they  attain  their  maximum 
intensity  sooner  than  in  the  passive  form.  In  passive  congestion  the 
development  of  symptoms  is  not  only  more  gradual,  but  they  are  ordi- 
narily less  pronounced,  and  are  attended  by  more  fluctuation  than  in 
the  active  form.  The  parah'sis,  if  present,  comes  on  slowly  after 
several  days  and  is  incomplete.  Spinal  congestion,  especially  of  the 
passive  form,  is  sometimes  associated  with  cerebral  congestion,  as  for  ex- 
ample in  tetanus  and  severe  eclampsia,  and  the  s])inal  symptoms  there- 
fore coexist  with  those  Avhich  have  a  cerebral  origin.  The  duration  and 
the  result  of  a  hypersemic  state  of  the  spinal  cord  and  its  meninges, 
depend  largely  on  the  nature  of  the  cause.  If  it  be  not  relieved  within 
a  few  days  there  is  strong  probability  that  some  other  serious  patho- 
logical state  has  supervened,  as  meningitis,  myelitis,  extravasation  of 
blood,  or  serous  transudation,  Avith  softening  of  the  nervous  substance. 

Treatment. — In  the  adult,  spinal  congestion  sometimes  results  from 
the  sudden  cessation  of  the  hemorrhoidal  or  catamenial  flow,  and  the 
application  of  leeches  or  wet  cups  along  the  spine  is  indicated.  But  in 
the  child,  the  abstraction  of  blood  is  seldom  required.  In  the  acute 
stage  of  active  spinal -congestion,  with  decided  febrile  movement,  cold 
applications  along  the  spine  are  often  beneficial,  as  by  an  India-rubber 
bag. 

In  active  hypersemia,  laxatives  are  useful,  and  rubefacient  applica- 


SPINA    BIFIDA.  547 

tions  should  be  made  along  the  spine,  as  by  mustard,  or  by  friction  with 
a  stimulating  liniment.  In  the  inflammatory  spinal  congestion  of  cere- 
bro-spinal  fever,  I  have  employed  with  a  very  satisfactory  result  a  lini- 
ment containing  equal  parts  of  camphorated  oil  and  turpentine.  In 
both  active  and  passive  hyperremia  lateral  decubitus  should  be  pre- 
scribed rather  than  dorsal.  The  use  of  ergot,  in  order  to  diminish  the 
turgescence  of  the  vessels  of  the  spinal  cord  and  meninges,  has  been  ad- 
vocated by  Brown-Seciuard,  and  it  is  now  one  of  the  recognized  reme- 
dies. Bromide  of  potassium  is  also  a  remedy  of  value,  but  it  is  more 
useful  in  certain  cases  than  in  others.  It  is  signalh^  beneficial  in  those 
cases  in  which  there  is  also  cerebral  congestion.  AVhen  the  congestion 
is  increased  or  produced  by  clonic  convulsions,  the  bromide  is  one  of 
the  most  reliable  remedies  Avhich  we  possess  for  the  removal  of  the  cause. 
Thus  it  should  be  employed  in  the  treatment  of  the  spinal  and  cerebral 
congestion  in  the  commencement  of  A'ariola,  in  which  convulsions  are 
so  common,  and  in  the  convulsions  of  pertussis,  which  cause  extreme 
passive  congestion  of  the  cei'ebrospinal  axis.  Passive  congestion  of  the 
spine,  common  in  exhausting  diseases,  and  due  to  feebleness  of  the  cir- 
culation, is  best  treated  by  stimulating  and  sustaining  remedies,  and  by 
the  lateral  decubitus.  It  is  hypostatic,  and  may  be  associated  with  a 
similar  congestion  in  the  posterior  part  of  the  lungs. 


CHAPTEK   XYIII. 

SPINA  BIFIDA. 

Tins  is  one  of  the  most  common  of  the  malformations.  In  its  severe 
form  it  is  from  its  nature  incurable,  admitting  only  of  palliative  treat- 
ment, while  in  its  milder  forms  it  may  be  cured,  or  so  relieved  as  not 
to  compromise  life.  The  term  spina  bifida  is  applied  to  a  hernia  of  the 
spinal  meninges,  Avhich  produces  a  rounded  tumor,  situated  posteriorly 
over  the  spine  in  the  median  line.  It  is  due  to  the  congenital  absence 
or  incompleteness  of  one  or  more  of  the  arches  of  the  vertebn\3.  In  ex- 
ceptional instances,  the  arch  is  said  to  be  complete  at  birth;  but  the 
lateral  portions  separate,  and  are  pressed  outwai'd  during  the  first  weeks 
of  life.  The  tumor  contains  the  cerebro-spinal  fluid,  and  unless  it  be 
small,  and  its  walls  unusually  thick,  fluctuation  may  be  detected  in  it. 
When  the  chihl  cries  tlie  tumor  enhirges,  and  it  is  reduced  by  conii)res- 
sion,  the  fluid  reentering  the  spinal  canal.  Jf  the  tumor  be  large,  its 
complete  subsidence  by  pressure  often  produces  dangerous  cerebral 
symptoms.  Spina  bifida  is  tlie  counterpart  of  hydroce])halus,  and  the 
two  often  coexist.  If  we  compress  the  hydrocephalic  head  the  spinal 
tumor  increases,  and  vice  versa.     Club-foot  is  another  not  infrequent 


5-i8 


SPINA    BIFIDA, 


complication.  In  the  case  Avliicli  is  represented  in  the  accompanying 
Avoodcut,  livdroceplialus,  spina  bifida,  and  clubfoot  coexisted.  Tlie 
child  was  brought  to  the  children's  class  in  the  Outdoor  Department  at 
Bellevue,  and  after  a  few  visits  I  lost  sight  of  it.  It  probably  died  soon 
after,  since  the  tumor,  over  which  the  cuticle  was  wanting,  presented 
a  deep  red  appearance  as  if  inflamed,  so  that  ulceration  and  escape  of 
the  fluid  seemed  near  at  hand.  There  is  ordinarily  but  one  spina  bifida, 
the  common  seat  of  which  is  the  lumbar  region,  but  occasionally  two  or 
more  are  present.  If  the  a})erture  through  which  the  tumor  protrudes 
be  small,  it  is  usually  pedunculated,  but  if  large,  it  is  sessile.  In  some 
patients  it  is  covered  by  skin,  which  may  be  normal  or  somewhat  indu- 
rated; in  others  the  skin  is  absent  over  the  entire  tumor  or  its  most 
prominent  part,  and  the  dura  mater  or  the  connective  tissue  lying  di- 
rectly over  the  dura  mater  is  exposed,  and  is  liable  to  inflamnuxtion  from 
friction.  If  the  walls  of  the  tumor  be  thin  the  liquid  may  transude  in 
drops,  and  they  are  liable  to  give  way  by  ulceration  or  rupture.     Sudden 


escape  of  the  liquid,  and  eolla]ise  of  the  spina  bifida,  involve  great  danger, 
for  convulsions,  coma,  and  death  arc  the  pvobid)lo  result. 

The  relation  of  the  spinal  cord  or  nerves,  or  of  the  cauda  equina,  to 
the  tumor,  is  a  matter  of  great  importance.  In  many  patients  the  adja- 
cent portion  of  the  cord  or  cau<la  equina,  is  deflected  through  the  aper- 
ture, and  lies  against  the  interior  of  the  sac.  Spinal  nerves  also  not  in- 
frequently lie  within  the  sac,  some  returning  into  the  spinal  canal,  and 
others  passing  through  the  walls  of  the  sac  to  their  })oints  of  distribu- 
tion. Those  which  are  deflected  into  the  tumor  and  return  into  the 
canal  obviously  lie  lowest.  In  the  most  favorable  cases,  to  wit,  those 
with  a  small  ai)erture,  or  small  tumor,  or  a  narrow  and  long  peduncle, 
neither  the  cord,  cauda  equina,  nor  nerves  lie  witliin  the  sac.  It  is  im- 
portant to  tlie  practitioner  to  bear  in  mind  that  in  all  ])robability,  unless 
under  the  favorable  anatomical  circumstances  stated  above,  the  sac  con- 
tains nervous  elements.  In  rare  instances  the  liquid,  instead  of  lying 
externally  to  the  cord,  lies  within  its  central  canal.     The  substance  of 


PROGNOSIS TKEATMEXT.  549 

the  cord  then  becomes  distended,  and  it  encloses  the  liquid  like  a  deli- 
cate sac,  just  as  the  hemispheres  of  the  brain  are  unfolded  and  expanded 
in  the  common  form  of  congenital  hydrocephalus.  As  might  be  expected 
from  the  anatomical  characters  of  the  more  serious  forms  of  spina  bifida, 
paralysis,  more  or  less  complete,  of  the  vesical  and  rectal  muscular 
fibres,  and  paraplegia  sometimes  occur,  in  which  event  the  fatal  issue  is 
probably  not  far  distant. 

Diagnosis. — This  is  easy  in  ordinary  cases.  The  congenital  nature 
of  the  tumor,  and  tlie  bony  edge  of  the  aperture,  appreciable  to  the 
touch,  suffice  in  ordinary  cases  to  establish  the  diagnosis.  The  diminu- 
tion of  the  tumor  by  pressure,  and  its  enlargement  when  the  child  cries, 
are  important  diagnostic  signs.  There  are  various  lumbo-sacral  tumors 
located  in  the  median  line,  from  which  it  is  important  that  spina  bifida 
should  be  diagnosticated.  Sometimes  a  cyst  occurs  in  this  situation 
Avliicli  was  originally  a  spina  bifida,  but  obliteration  of  the  canal  in  the 
pedicle  occurred,  just  as  the  canal  connecting  a  hydrocele  with  the 
abdominal  cavity  closes.  Solid  congenital  tumors  sometimes  also  occur 
in  the  same  situation,  among  Avhich,  as  most  common,  may  be  men- 
tioned fatty  tumors,  and  tumors  containing  foetal  remains.  The  most 
common  seat  of  tumors  which  enclose  fetal  remains  is  at  the  point 
where  spina  bifida  ordinarily  occurs.  Physicians  have  erred  in  con- 
f  )unding  these  tumors,  as  Avell  as  those  which  consist  of  fat,  with  spina 
bifida ;  but  a  mistake  in  diagnosis  can  only  occur  through  haste  or 
carelessness  of  examination. 

Prognosis. — This  is  in  most  instances  unflivorable.  Ordinarily  the 
tumor  increases  slowly,  and  finally  the  sac  gives  way  by  ulceration  or 
rupture ;  the  liquid  escapes,  and  death  occurs  in  convulsions  and  coma; 
or,  if  the  escape  of  the  liquid  be  prevented  by  pressure,  and  the  aper- 
ture closes,  a  second  rupture  is  probable  with  a  fatal  result.  In  other 
cases  the  tumor  may  not  rupture,  but  the  cord  is  softened,  or  it  is  in- 
jured by  being  bent,  so  that  paraplegia  results,  and  death  after  a  time 
occurs  in  a  state  of  emaciation.  Rarely  the  tumor  may  shrivel  by  ab- 
sorption of  the  liquid,  and  the  disease  is  cured,  or  so  nearly  cured  that 
it  gives  no  inconvenience,  and  the  patient  lives  for  years.  In  other 
rare  instances  the  tumor  may  remain  without  any  material  change,  and 
without  giving  rise  to  symptoms.  The  sj)ina  bifida  being  small  and 
covered  with  skin,  and  the  aperture  leading  from  it  into  the  spinal  canal 
being  also  small,  the  patient  lives  through  the  natural  })eriod  of  life  Avith 
little  inconvenience. 

Treatment. — It  is  evident,  from  what  has  been  stated,  tliat  no  fixed 
rule  can  be  laid  down  f  )r  the  treatment  of  the  spina  bifida.  In  the 
most  favorable  cases,  in  wliich  no  symptoms  occur,  and  there  is  no  indi- 
cation that  the  tumor  will  change  or  undergo  any  unfavorable  change, 
surgical  ti-eatment  is  not  rei^uirod,  except  the  application  of  a  soft  pad 
to  su[)port  the  tumor,  so  as  to  prevent  its  injury  by  friction.  Indications 
which  justify  active  surgical  interference  are  growth  of  tumor,  absence 
of  skin  from  it,  with  tension  of  the  parietes,  so  that  an  early  rupture  is 
inevitable,  and  dangerous  nervous  symptoms,  as  convulsions  or  para- 
j)legia. 

From  the  nature  of  sj)ina  bifida  it  is  evident  that  operations  upon   it 


550  SPINA    BIFIDA. 

must  be  conducted  with  caution.  The  usual  presence  of  the  spinal  cord 
in  the  pedicle  and  in  the  sac  forbids  ligation  and  excision,  and  renders 
attempts  to  obliterate  the  sac  liazardous,  by  producing  inflammation 
■\vithin  it.  A  safe  mode  of  treatment,  but  not  the  most  efficient,  is  to 
puncture  the  sac  and  withdraw  a  portion  of  the  li([uid  by  a  grooved 
needle  or  hypodermic  syringe.  A  soft  pad  should  then  be  applied  to 
produce  gentle  compression.  If  no  unfavorable  symptoms  occur,  the 
puncture  may  be  repeated  after  a  day  or  two.  This  operation  has  been 
employed  with  a  satisfactory  result  by  Sir  Astley  Cooper  among 
others;  but,  simple  as  it  is,  it  is  not  devoid  of  danger,  for  the  removal 
of  the  liquid,  if  carried  beyond  a  certain  ])oint,  may  produce  dangerous 
nervous  symptoms,  especially  convulsions.  In  performing  the  opera- 
tion, the  puncture  should  never  be  made  in  the  median  line,  on  account 
of  the  danger  of  wounding  the  cord,  Avhich  lies  against  the  median  por- 
tion of  the  sac.     The  veins,  also,  should  be  avoided. 

Another  mode  of  treatment  is  by  iodine  injections.  They  are  pre- 
ferable to  other  methods,  if  the  neck  be  long  and  pedunculated,  so  as  to 
be  easily  compressed.  If  the  tumor  be  sessile,  and  the  aperture  into  the 
spinal  canal  be  free,  these  injections  involve  great  danger,  and  are  not 
to  be  recommended  ;  for  more  or  less  of  the  solution  will  inevitably  enter 
the  spinal  canal,  and  give  rise  to  spinal  meningitis.  Iodine  injections 
have  been  employed  with  success  by  Professor  Brainard,  of  Chicago, 
who  states  that  he  "perfectly  and  permanently  cured"  three  of  seven 
cases ;  and  by  Velpeau,  of  Paris,  by  whose  method  five  in  ten  opera- 
tions were  successful,  and  by  many  others.  Professor  Brainard  with- 
drew some  of  the  liquid  contents,  and  then  injected  half  an  ounce  of  water 
containing  2^^  grains  of  iodine,  and  7^  grains  of  iodide  of  potassium.  In 
a  few  seconds  this  Avas  allowed  to  flow  out,  and  the  sac  was  then  washed 
out  with  tepid  water.  Then  a  portion  of  the  cerebro-spinal  fluid,  which 
had  been  kept  warm,  was  returned  into  the  sac.  When  he  had  with- 
drawn six  ounces  of  this  fluid  he  returned  two  ounces.  In  employing  the 
iodine,  or  any  other  irritating  injection,  it  is  necessary  to  compress  the 
pedicle,  so  that  the  liquid  does  not  enter  the  spinal  canal.  Velpeau 
employed  one  part  of  iodine,  one  of  iodide  of  potassium,  and  ten  of  dis- 
tilled water. 

During  a  debate  in  the  Societe  de  Chirurgie,  M.  Debout  recom- 
mended the  evacuation  of  only  a  little  of  the  fluid,  and  the  injection  of 
two  or  three  drops  of  the  tincture  of  iodine  diluted  with  an  equal  quan- 
tity of  water,  T.  Smith,^  by  the  injection  of  one  drop  of  the  tincture, 
produced  an  amount  of  inflammation  which  nearly  obliterated  the  sac. 
Since  statistics  show  so  good  a  result  of  iodine  injections,  this  mode  of 
treatment  seems  preferable  to  any  other  for  certain  cases,  and  as  one 
drop  has  produced  general  inflammation  of  the  sac  and  nearly  oblite- 
rated it,  it  seems  safest  and  best  to  begin  with  so  small  a  quantity. 

If  there  be  reason  to  believe,  from  the  small  size  of  the  orifice  and 
other  anatomical  characters,  that  neither  the  cord,  Cauda  equina,  nor  any 
of  the  spinal  nerves  lie,  within  the  sac,  it  may  be  thought  best  to  remove 
the  tumor.     It  has,  indeed,  been  proposed  to  open  the  tumor,  immersed 

'  Holmes's  Surg.  Dia.  of  Children. 


VERTEBRAL    CARIES.  551 

under  warm  water  sufficiently  to  observe  tlie  relation  of  the  nervous  ele- 
ments, and  to  press  them  back  gently  into  the  canal  if  they  lie  within 
the  sac.  If  it  be  decided  to  remove  the  spina  bifida,  a  clamp,  or  elastic 
band,  is  placed  around  the  pedicle  so  snugly  as  to  cause  firm  adhesion 
of  the  Avails  of  the  pedicle,  and  excite  sufficient  inflammation  in  them 
to  produce  agglutination,  but  without  causing  strangulation  or  sup- 
puration. 

After  a  time,  perhaps  two  or  three  days,  when  it  is  evident  that  agglu- 
tination has  occurred  from  the  fact  that  the  liquid  cannot  be  returned 
within  the  spinal  canal  by  compressing  the  sac,  the  tumor  may  be  re- 
moved by  the  knife  or  ecraseur.  Statistics  do  not  show  so  favorable  a 
result  of  this  operation  as  of  the  iodine  treatment,  and  the  reason  is 
obvious  for  it  is  only  in  exceptional  cases  that  the  tumor  can  be  re- 
moved without  injury  to  the  nervous  tissue,  and  excision  of  a  portion 
of  the  cord,  or  of  important  nerves,  either  produces  death  or  a  condi- 
tion to  which  death  would  be  a  relief. 

Spina  bifida  has  also  been  treated  by  opening  the  sac  on  its  side, 
])ressing  back  the  spinal  cord  or  its  nerves  into  the  spinal  canal,  uniting 
the  edges  of  the  wound,  and  then  applying  pressure  to  prevent  protru- 
sion, but  the  result  has  not  been  favorable.  Treatment  by  simple 
puncture,  followed  by  comuression,  and  if  it  fail,  as.it  probably  will, 
the  cautious  use  of  iodine  injections  is  the  preferable  mode  of  treating 
ordinary  cases  of  spina  bifida  which  require  surgical  interference. 


CHAPTER    XIX. 

TEIiTEBRAL  CAEIES. 

Vertebral  caries,  designated  also  Pott's  disease,  occurs  chiefly  in 
childhood,  but  now  and  then  adults  are  affected  with  it.  It  is  an  osteitis 
of  the  bodies  of  one  or  more  vertebra},  ending  in  their  ulceration  and  a 
lifelong  deformity,  if  not  checked. 

Causes. — A.  reduced  state  of  system,  and  especially  the  scrofulous 
diathesis,  strongly  predispose  to  caries.  Hence  this  malady  is  more 
common  in  the  city  than  in  the  country,  where  better  hygienic  condi- 
tions ))r()duce  a  more  vigorous  constitution.  Prolonged  antihygienic 
conditions  and  protracted  ill-health  from  whatever  cause  predispose  to 
caries.  In  certain  cases,  there  is  no  apparent  exciting  cause,  while  in 
others  there  is  the  history  of  a  fall  upon  or  si^mo  injury  of  the  spine. 

Vertel)ral  caries  may  occur  in  the  cervical,  dorsal,  or  lumbar  ])ortions 
of  the  spinal  column,  but  it  is  more  common  in  the  lower  dorsal  than 
elsewhere.  With  the  development  of  the  osteitis,  the  l)ody  of  the  verte- 
bra which  is  affected  becomes  hypera^mic,  and  the  spongy  tissue  is  soon 


552  VERTEBRAL    CARIES. 

infiltrated  with  blood  and  pus.  The  bone  becomes  swollen  and  softened, 
and,  therefore,  less  resisting  than  in  the  healthy  state,  so  that  it  yields 
under  the  weight  of  the  shoulders  and  head,  which  it  sustains.  There- 
fore, after  the  osteitis  has  continued  a  certain  time,  there  begins  to  be 
posterior  convexity  or  rather  angularity  of  the  spine,  for  Avhile  the  verte- 
bral bodies  soften  and  yield  by  the  weight  above  them,  the  arches  retain 
their  integrity  and  firmness,  and  are  unyielding. 

Much  of  the  tediousness  and  suffering  of  this  malady  are  due  to  the 
fact  that  the  inflammation  is  so  deep-seated,  and  a  healthy  bony  barrier 
is  interposed  between  it  and  the  surface,  so  that  there  is  no  ready  escape 
of  the  pus.  It  permeates  the  spongy  tissue,  filling  the  cavities  produced 
by  the  softening  and  absorption  of  the  bone-substance.  If  the  inflam- 
mation be  of  small  extent,  the  amount  of  pus  small,  the  constitution 
good,  and  if  the  disease  be  early  recognized  and  properly  treated,  the 
child  may  recover  without  any  fistulous  opening,  by  absor2)tion  of  the 
pus,  and  with  little  remaining  deformity. 

In  the  large  proportion  of  cases,  however,  the  history  is  different. 
The  disease  is  not  recognized  till  the  stage  of  deformity,  the  caries  is  so 
extensive  and  the  pus  so  abundant,  that  it  escapes  between  the  vertebree, 
forming  an  abscess  external  to  them,  which  connects  with  the  interior 
of  the  vertebrfB  by  a  fistulous  canal.  This  abscess  if  in  the  cervical 
region  may  press  upon  the  pharynx  or  oesophagus,  or  upon  the  air-])as- 
sages,  producing  dangerous  obstruction  to  the  respiration.  (See  Art. 
Retro-|)haryngeal  Abscess.)  The  pus  may  point  and  discharge  exter- 
nally near  the  seat  of  the  caries,  but  in  a  large  proportion  of  instances 
it  takes  a  long  and  circuitous  route  to  the  surface,  or  it  opens  internally. 
There  are  instances  in  which  it  discharges  into  the  pleural  or  abdominal 
cavity,  or  into  one  of  the  abdominal  organs.  If,  as  is  sometimes  the 
case,  it  establishes  a  connection  with  the  intestine  and  escape  in  the 
stools,  the  result  will  probably  be  favorable.  In  other  instances  it 
descends  into  the  pelvic  cavity,  and  finds  an  outlet  by  the  inguinal  ring, 
or  sciatic  notch,  or  it  enters  the  sheath  of  the  iliacus  or  psoas  muscle, 
and  points  externally. 

When  the  disease  ends  favorably,  new  bone  is  thrown  out  around  the 
diseased  vertebrae,  preventing  further  bending,  and  giving  stability  to 
the  spine.  If  the  abscess  do  not  discharge,  but  remain  subcutaneous, 
Billroth  says:  .  .  .  "While  the  bone  disease  recovers  most  fre- 
quently, a  large  part  of  the  pus,  whose  cells  disintegrate  into  fine  mole- 
cules, is  absorbed,  while  the  inner  walls  of  the  abscess  change  to  a  cica- 
tricial tissue,  which  in  the  shape  of  a  fibrous  sac  contains  the  jjuriform 
fluid.      Such  pus-sacs  often  remain  in  this  stage  for  years." 

If  the  pus  have  escaped  externally,  the  abscesses  and  fistula)  contract 
and  finally  close,  their  site  being  occupied  by  condensed  connective 
tissue.  The  portions  of  the  diseased  vertebrae  which  have  retained  their 
vitality  are  envelo|)ed  and  supported  l)y  the  new  bone,  so  that  the  ])art 
of  the  spine  which  was  the  seat  of  the  disease,  though  anchyloscd  and 
curved,  has  greater  firmness  than  in  health. 

The  history  of  unfavorable  cases  varies;  the  caries  may  extend.  Pus 
finding  no  vent  may  accumulate  in  cavities  and  sinuses,  in  which  de- 
tached portions  of  bone  float,  or  it  may  make  its  way  in  such  directions 


DIAGXOSiS.  553 

that  it  produces  alarming  complications,  and  impairs  or  obstructs  the 
functions  of  important  organs. 

Spinal  meningitis  in  the  vicinity  of  the  caries,  and  due  to  extension 
of  the  inflammation,  is  common,  and  ''the  spinal  medulla,"  says  Bill- 
roth, "  may  be  endangered  by  participation  in  the  suppuration,  or  by 
beino-.  so  bent  by  the  inclination  of  the  vertebrae,  that  its  function  is 
destroyed."  Hence  the  paralysis  of  the  lower  extremities,  bladder,  and 
rectum,  Avhieli  occurs  in  aggravated  cases,  and  which  entails  a  fatal  issue. 
In  a  certain  proportion  of  cases  the  blood  becomes  more  and  more  im- 
poverished from  the  continuance  of  the  inflammation  and  suppuration, 
and  death  occurs  in  a  state  of  exhaustion.  In  such  cases  post-mortem 
examination  often  discloses  waxy  degeneration  of  important  organs,  as 
the  spleen,  liver,  kidne^^s,  and  intestines,  for  it  is  Avell  known  that 
chronic  suppurative  inflammation  of  the  bones  is  one  of  the  two  chief 
causes  of  the  waxy  disease,  syphilis  being  the  other. 

Symptoms. — Caries  of  the  vertebrre  is  often  preceded  by  symptoms 
or  appearances  which  are  due  to  the  strumous  cachexia.  Strumous 
ailments  have  probably  occurred  in  the  patient,  or  in  members  of  the 
family,  or  without  any  clear  history  of  struma  the  child  has  perhaps  for 
some  time  been  in  failing,  health.  In  cases  which  I  have  observed,  one 
of  the  chief  symptoms,  and  sometimes  almost  the  only  symptom  in  the 
co:nmencement  of  the  caries,  has  been  neuralgic  pain,  usually  not  severe, 
intermittent,  or  more  or  less  constant,  at  some  point  in  the  anterior 
aspect  of  the  body,  most  frequently  in  the  chest,  epigastric,  or  umbilical 
region.  This  pain  has  been  present  in  a  larger  proportion  of  cases, 
than  pain  in  the  spinal  region  at  the  seat  of  the  caries,  though  Guersant 
dwells  particularly  upon  the  latter  as  a  symptom  of  caries.  Patients 
with  this  neuralgia  are  not  infrequently  treated  for  indigestion,  or 
worms,  the  true  nature  of  the  malady  not  being  suspected,  and  the  spine 
not  even  being  examined.  This  neuralgia  seems  to  be  due  to  compres- 
sion of  the  spinal  nerves,  by  inflammatory  exudation  at  the  points  where 
they  emerge  from  the  spinal  canal.  I  can  recall  to  mind  a  number  of 
cases  in  which  I  have  on  difl'erent  occasions  been  asked  to  prescribe  for 
this  neuralgia,  which  was  shown  by  the  sequel  to  be  undoubtedly  the 
result  of  vertebral  caries,  and  yet  with  a  careful  examination  of  the 
spinal  column  could  discover  no  evidences  of  disease  at  any  point.  After 
a  time,  tenderness,  pain,  and  inflammatory  induration,  appreciable  to  the 
touch,  may  occur  in  or  along  the  spine,  but  not  usually  till  the  malady 
is  well  advanced.  Lassitude,  fatigue  after  slight  exertion,  poor  appetite, 
with  slight  fever,  are  common  symptoms  in  the  first  stage  of  the  caries. 

As  the  case  advances,  if  the  nature  of  the  disease  be  not  recog- 
nized, and  no  artificial  support  of  the  trunk  be  provided,  the  child  in- 
stinctively seeks  some  way  of  supporting  the  head  and  shoulders.  He 
rests  his  head  upon  his  hands,  or  his  elbows  ui)on  the  table.  Soon  a 
gibl)ositv  or  angularity  ajipears,  aff'ording  clear  and  positive  proof  of  the 
nature  of  the  disease.  Even  now  there  is  little  or  no  tenderness  when 
]»ressure  is  made  directly  on  the  spine,  but  it  is  observed  more  when 
])ressure  is  made  laterally  upon  it.  If  the  inflammation  extend  so  as  to 
involve  the  meninges  and  the  cord,  pricking,  tingling,  numbness  or 
weakness  of  the  legs  may  occur,  which  are  symptoms  of  grave  import, 


554  VERTEBRAL    CARIES. 

for  it  is  probaljle  that  the  case  Avill  end  iu  })araplegia  and  death.  A 
state  of  emaciation  and  general  weakness,  sometimes  accompanied  by 
diarrhoea  and  oedema  of  the  limbs,  precedes  death.  But  a  very  consid- 
erable degree  of  curvature  is  not  incompatible  with  a  healthy  and  normal 
performance  of  all  the  functions,  and  the  numljcr  who  recover,  and  live 
to  an  advanced  age  Avith  deformity,  is  large,  as  every  one  knows. 

Diagnosis. — This  is  often  from  the  nature  of  the  disease  obscure  and 
uncertain  for  a  time.  The  long  continuance  of  pain  in  the  chest  or 
abdomen,  or  perhaps  in  the  thighs,  without  any  cause  which  we  can  de- 
tect, located  at  the  seat  of  the  pain,  should  excite  suspicion  of  spinal  dis- 
ease. Such  pain  may  be  produced  by  spinal  irritation,  but  in  this 
malady  pressure  on  tlie  spine  is  badly  tolerated,  and  when  we  touch  a 
certain  part,  the  neuralgic  pain  is  intensified.  In  caries,  as  we  have 
seen,  firm  pressure  upon  the  spine  is  tolerated,  and  it  does  not  increase 
the  neuralgia.  At  a  later  period  in  caries  there  may  be  spinal  pain 
and  tenderness,  but  there  is  now  also  spinal  deformity,  by  which  alone 
the  diagnosis  is  clearly  established;  stiflihcss  observed  in  the  movements 
of  the  spine,  pain  in  the  spine,  on  sudden  nujvement  or  jarring  the  body, 
impaired  aj)j)etite  and  general  health,  and  instinctive  desire  to  sit  or 
recline  in  such  a  way  as  to  relieve  the  spine  partially  of  the  weight  of 
the  head  and  shoulders,  are  symptoms  which,  if  they  coexist,  afford  very 
sti'ong  evidence  of  the  presence  of  caries,  although  there  be  as  yet  no 
deformity. 

The  spinal  deformity  of  rachitis  is  distinguished  from  that  of  caries, 
by  the  fact  that  it  occurs  slowly  without  pain  or  tenderness,  and  is 
rounded  instead  of  angular.  JNIoreover,  the  rachitic  diatliesis  precludes 
scrofulous  ailments,  and  the  scrofulous  diathesis  rachitic  ailments,  as  the 
two  diatheses  do  not  coexist,  or  but  rarely ;  so  that  if  there  be  in  the 
state  of  the  patient  or  have  been  in  his  history  evidences  of  scrofula,  the 
])resumption  is  that  the  bending  of  the' spine  occurs  from  caries.  In  a 
case  of  rachitic  curvature,  we  find  also  enlargements  of  the  ankles  and 
wrists,  keel-shaped  thorax,  prominent  abdomen,  rachitic  head,  etc. 

Prognosis. — The*  course  of  this  malady,  even  when  the  caries  is 
slight  and  tlie  symptoms  mild,  is  tedious.  In  the  most  favorable  cases 
the  general  health  is  but  slightly  impaired,  the  caries  is  confined  to  one 
vertebra,  and  is  early  diagnosticated  and  jiroperly  treated.  On  the 
other  hand,  if  the  general  health  be  decidedly  poor,  the  child  anaemic, 
and  wasted,  the  curvature  great,  and  an  abscess  have  occurred,  the  case 
is  very  serious,  BetAveen  these  two  extremes  is  every  grade.  The 
prognosis  is  more  favorable  in  the  child  than  in  the  adult.  The  few 
adults  whom  I  have  seen  with  it  all  died.  It  is  less  favorable  in  the 
cervical  region  than  in  the  dorsal  or  luml)ar.  A  mild  case  occurring  in 
a  go<)<l  condition  of  health  may  become  grave  and  even  fatal  by  neglect 
and  improper  treatment.  A  majority  of  the  patients,  if  the  disease  be 
not  too  far  advanced  when  recognized,  recover  if  properly  treated,  but 
the  deformity  which  results  may  prove  serious  in  after-life.  The  incom- 
plete expansion  of  the  lungs  in  the  humpbacked,  greatly  increases  the 
danger  and  the  dyspnoea  in  bronchitis  and  pneumonia,  and  if  the  caries 
liave  been  at  a  low  point  in  the  spine,  and  the  patient  a  female,  the  de- 
formity will  probably  })resent  an  obstacle  to  childbearing. 


TREATMENT.  OOO 

Treatmext. — The  treatment  must  be  constitutional  and  local,  hy- 
crienic,  medicinal,  and  mechanical.  It  is  of  the  utmost  importance  to 
improve  the  general  health,  as  it  is  in  all  chronic  inflammations  and 
scrofulous  ailments.  Pure  air,  sunlight,  personal  cleanliness,  and  plain 
but  the  most  nutritious  diet  are  required.  Tonic  and  antistrumous 
remedies  are  indicated.  To  many  patients  I  have  prescribed,  three 
times  daily,  cod-liver  oil,  to  which  the  syrup  of  the  iodide  of  iron  was 
added,  giving  two  drops  to  a  child  of  one  year,  and  one  additional  drop 
for  each  additional  year.  The  judicious  use  of  alcoholic  stimulants  will 
often  be  found  useful,  if  the  appetite  be  poor  and  general  health  seri- 
ously impaired,  as  will  also  the  vegetable  bitters. 

In  all  strumous  inflammations  of  the  bones,  which  extend  to  or  in- 
volve joints,  and  which  are  in  their  nature  chronic,  perfect  quiet  of  the 
parts,  so  far  as  it  is  consistent  with  the  degree  of  exercise  which  is  re- 
quired in  order  to  improve  the  appetite  and  general  health,  is  indispen- 
sable for  successful  treatment  of  the  case.  The  patient  with  this  malady 
should  be  encouraged  to  lie  much  of  the  time  in  bed,  for  the  double 
purpose  of  preventing  movements  of  the  inflamed  vertebree,  and  re- 
lieving them  of  the  weight  of  the  shoulders  and  head.  But  confinement 
in  bed  is  badly  tolerated,  and  exercise  is  necessary  for  a  healthy  func- 
tional activity  of  the  organs ;  therefore  mechanical  support  of  the  spine 
is  required.  The  apparatuses  which  have  been  invented  for  the  purpose 
of  supporting  the  spine  and  rendering  it  immovable,  and  of  sustaining 
the  head,  if  the  caries  be  in  the  cervical  region,  or  the  head  and  shoul- 
ders, if  it  be  in  the  dorsal  or  lumbar  region,  are  ingenious  and  effectual. 
Some  of  tliem  are  rather  cumbersome,  but  others  are  sufficiently  light 
for  the  youngest  child  Avho  can  walk.  The  apparatus  should  be  worn 
for  months,  care  being  taken  to  prevent  excoriation  or  undue  pressure 
upon  any  point.  It  may  be  removed  at  night,  and  reapplied  on  rising 
in  the  morning. 


SECTION   IT. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CHAPTEK    I. 

COEYZA. 

The  term  coryza  is  applied  to  inilammation  of  the  Schneiderian 
membrane.  It  is  acute  or  chronic.  The  acute  form  is  primary  or  sec- 
ondary. Acute  primary  coryza  is  common  in  infancy  and  childhood. 
Its  usual  cause  is  exposure  to  currents  of  air,  to  cold,  and  especially  to 
sudden  changes  of  temperature  from  warm  to  cold.  The  cause  is  the 
same  as  that  in  the  ordinary  forms  of  bronchitis.  These  two  diseases 
frequently  indeed  coexist,  occurring  from  the  same  exposure.  The  in- 
flammation in  such  cases  commences  upon  the  Schneiderian  membrane, 
immediately  upon  the  operation  of  the  cause,  and  soon  after  extends  to 
the  bronchi:)]  tubes.  Acute  coryza  may  also  be  produced  by  the  inha- 
lation of  irritating  vapors,  hot  air,  or  dust,  and  also  by  the  presence  of 
a  foreign  body,  as  a  button  or  bean,  in  the  nostril. 

Secondary  coryza  is  commonly  due  to  a  specific  cause.  The  diseases 
in  connection  with  which  it  occurs  are  hooping-cough,  measles,  scarlet 
fever,  diphtheria,  and  constitutional  syphilis.  In  the  infant,  coryza  is 
one  of  the  first  manifestations  of  hereditary  syphilitic  taint. 

Acute  primary  coryza  ordinarily  abates  in  from  one  to  two  weeks. 
The  secondary  form  gradually  declines,  in  most  cases,  when  the  primary 
affection  on  which  it  depends  is  cured.  Syphilitic  coryza  is  more  pro- 
tracted than  the  primary  form,  or  than  that  accompanying  the  eruptive 
fevers.  Some  children  are  so  liable  to  coryza  that  it  occurs  whenever 
they  take  cold.  Occasionally  it  is  so  frequently  renewed  in  the  winter 
months  that  it  resembles  the  chronic  form  of  the  disease. 

Chronic  coryza  is  commonly  dependent  on  a  dyscrasia,  usually  the 
syphilitic  or  strumous.  The  dyscrasia  is  indicated  by  pallor,  flabbiness  of 
the  flesh,  and  liability  to  glandular  swellings.  Certain  cases  take  their 
origin  in  the  nasal  catarrh  of  the  exanthematic  fevers,  the  local  affec- 
tion continuing  after  the  constitutional  disease  has  declined.  Chronic 
coryza  sometimes  occurs  in  children  who  appear  otherwise  in  good 
health.  It  is  probable  that  in  such  cases  there  is  a  dyscrasia  of  which 
the  coryza  happens  to  be  the  sole  manifestation. 
(  556  ) 


SYMPT0:MS PKOGXOSIS TREAT:\rEXT.  oo7 

AxATO.MiCAL  Characters. — The  alterations  which  the  nasal  mu- 
cous membrane  undergoes  when  inflamed  vary  considerably  in  difi"erent 
cases.  In  the  simplest  and  most  common  form  of  coryza,  this  mem- 
brane is  sometimes  in  patches,  sometimes  generally  reddened,  thick- 
ened, and  softened.  Its  papillai  are  prominent,  producing  an  inequality 
of  the  surface.  Ulcerations  are  not  common  in  simple  acute  coryza, 
but  they  sometimes  occur  in  the  chronic  form. 

In  diphtheria,  and  sometimes  in  scarlet  fever  and  variola  of  severe 
type,  the  coryza  is  pseudo-membranous,  and  when  it  presents  this  form 
it  is  commonly  but  not  always  associated  with  pseudo-membranous 
anjiina  or  larvntjitis.  A  case  of  pseudo-membranous  corvza  occui'rinf; 
in  measles  is  related  by  M.  Guibert.  The  patient  was  a  rachitic  boy, 
three  and  a  half  years  old.  The  pseudo-membrane,  in  grave  cases, 
may  cover  almost  the  entire  surface  of  the  nostrils,  but  ordinarily  it 
occurs  in  patches. 

Symptoms. — The  constitutional  symptoms  are  mild  or  severe,  accord- 
ing to  the  gravity  of  the  inflammation.  If  the  coryza  be  acute  and 
pretty  general,  there  is  febrile  movement,  with  thirst  and  loss  of  appe- 
tite. Frontal  headache  is  common,  from  the  proximity  of  the  inflam- 
mation to  the  head,  or  its  extension  to  the  frontal  sinuses.  Sneezing  is 
the  first  symptom  in  many  cases  of  acute  coryza.  As  the  inflamed 
membrane  swells,  more  or  less  obstruction  occurs  to  respiration.  The 
breatliing  is  noisy,  especially  during  sleep,  and  in  severe  cases  the  pa- 
tient is  compelled  to  breathe  mostly  tlirough  the  mouth.  If  there  be 
much  obstruction  to  respiration  the  suffering  of  the  patient  is  consider- 
able, from  the  sensation  of  fulness  in  the  nostrils,  the  headache,  and  the 
muscular  eff'ort  required  in  each  respiratory  act. 

In  the  commencement  of  coryza  the  patient  experiences  a  sensation 
of  dryness  in  the  nostrils,  which  is  soon  succeeded  by  a  thin  discharge 
of  a  serous  appearance.  In  the  course  of  a  fcAV  hours  tlie  secretion 
becomes  thicker.  It  is  muco-purulent,  and  remains  such  till  the  disease 
begins  to  decline.  Inspissated  mucus  and  crusts  are  liable  to  collect 
within  the  nostrils  and  around  tlieir  orifice  in  chronic  coryza,  and  some- 
times also  in  the  acute  disease,  if  the  discharge  be  not  abundant.  These 
crusts  increase  the  difficulty  of  breathing.  Often  the  acridity  of  the 
discharge  is  such  that  the  skin  of  the  upper  lip  and  around  the  nostrils 
is  excoriated. 

Prognosis — Uncomplicated  catarrhal  coryza  rarely  terminates  fatally. 
It  is  only  dangerous  in  young  nursing  infants,  in  whom  it  may  seriously 
interfere  with  lactation.  Coryza,  accompanying  the  eruptive  fevers, 
altliough  it  may  increase  the  suffering,  does  not  materially  increase  the 
danger.  Syi)hilitic  coryza  subsides  when  the  system  is  sufficiently 
affected  by  antisyphilitic  remedies.  Chronic  coryza  is  sometimes  very 
obstinate.  It  may  continue  for  months  or  years,  giving  rise  to  a  con- 
stant, but  often  not  abundant,  discharge. 

Treatment. — Common  mild  attacks  of  corvza  require  little  treat- 
ment. The  bowels  should  be  kept  open,  the  feet  soaked  in  mustard- 
water,  and  the  body  should  be  warmly  clothed.  Inunction  of  the  nos- 
trils is  a  popular  remedy,  and  it  seems  to  give  some  relief.  If  coryza 
commence  •with  symptoms  which  indicate  a  pretty  severe  attack,  and 


558  CORYZA. 

there  are  evidences  of  extension  of  the  disease  toward  the  bronchial 
tubes,  an  emetic  of  syrup  of  ipecacuanha,  given  at  an  early  period,  mode- 
rates the  severity  of  the  inflammation  antl  may  prevent  the  occurrence 
of  bronchitis.  Afterward  a  simple  diaphoretic  mixture,  as  the  follow- 
ing, should  be  given : 

R. — SjTupi  ipecacuanha        ......      ^ij. 

S[iiril  iuther.  iiiir.  ......      ^j. 

Syrupi  siini)licis ^ij. — Misce. 

One  teaspoonful  every  three  hours  to  a  child  of  six  months.  In  place 
of  sweet  spirits  of  nitre,  acetate  of  potassium  may  be  employed  in  the 
dose  of  one  or  two  grains  for  infants;  and  if  there  be  decided  febrile  re- 
action, from  half  a  minim  to  two  minims,  according  to  the  age,  of  tinc- 
ture of  digitalis,  should  be  added  to  each  dose. 

A  three  to  five  per  cent,  solution  of  common  salt  in  warm  water  in- 
jected into  the  nostrils  with  a  small  syringe,  aids  materially  in  removing 
the  muco-pus  which  obstructs  the  respiration,  and  in  establishing  a 
healthier  state  of  the  inflamed  surface.  I  have  employed  in  the  same 
Avay,  with  ajiparent  benefit,  carbolic  acid,  glycerine  and  water,  to  which 
the  borate  of  sodium  or  a  few  grains  of  chlorate  of  potassium  have  been 
added.  This  may  also  be  conveniently  used  in  the  form  of  spray,  with 
the  steam  atomizer,  or  thrown  up  the  nostrils  with  the  hand  atomizer. 
The  officinal  lime-water  is  also  a  most  useful  detergent  of  the  nasal  sur- 
face. The  following  formula  will  be  found  useful  in  most  cases  of  this 
form  of  coryza.     It  should  be  injected  warm  several  times  daily  : 

R. — S"dii  chloridii        .......      3J. 

S.idii  borat ^ij. 

Aqute    .......  .     Oj. — Misce. 

The  treatment  proper  for  pseudo-membranous  or  diphtheritic  coryza 
is  detailed  in  our  remarks  on  the  therapeutics  of  diphtheria.  Chronic 
coryza,  since  it  depends  upon  a  dyscrasia,  of  which  it  is  one  of  the  local 
manifestations,  requires  remedies  appropriate  for  the  blood  disease. 
Scrofula  needs  the  syrup  of  the  iodide  of  iron  and  cod-liver  oil.  The 
various  ferruginous  preparations,  as  Avine  of  iron,  tincture  of  the  chloride 
of  iron,  iron  lozenges,  and  the  vegetable  tonics  are  also  more  or  less  use- 
ful. The  diet  should  be  nutritious  and  plain,  and  outdoor  exercise, 
and,  if  possible,  country  life,  should  bo  enjoined. 

If  the  dyscrnsia  be  syphilitic,  similar  invigorating  measures  are  re- 
quired, and  mild  mercurial  inunctions  to  the  nasal  surface  are  especially 
useful.  The  following,  which  has  been  largely  employed  in  the  Out- 
door Department  at  Bellevue,  is  one  of  the  best  ointments  for  such 
cases,  and  its  alterative  effect  renders  it  also  useful  for  strumous  coryza : 

R. — Un<^.  hydrari^.  nitratis  ......       5ij. 

Ung.  zinci  oxid.    .......      5ij. — Misce. 

To  1)0  thoroughly  applied  to  the  Rchneiderian  membrane  by  a  swab 
or  camel's-hair  pencil  three  or  four  times  daily.  Recently  it  has  been 
modified  by  the  substitution  of  Squibb's  five  per  cent,  oleate  of  mercury 


CATARRHAL    LARYNGITIS.  559 

in  place  of  the  citrine  ointment.  If  the  coryza  have  a  distinctly  syphilitic 
ori<i:in,  the  application  of  a  two  or  three  per  cent,  oleate  of  mercury  will 
fully  meet  the  indication  and  be  followed  by  improvement. 

Mei«TS  and  Pepper  recommend  the  following  ointment  in  chronic 
coryza,  to  be  applied  at  night,  after  the  use  of  injections  through  the 
day  : 

R. — Unguenti  hydrargyri  nitratis        ....      ^ss. 

Exiracti  belladunnoe      .         .         .         .         .         .     gr.  x. 

Axungia3       ........      .^ss. — Misce. 

Astringent  injections  into  the  nostrils  are  not  often  required  in  the 
treatment  of  the  various  forms  of  coryza;  but  occasionally,  if  the  dis- 
charge be  protracted  and  abundant,  weak  astringent  applications  may 
be  beneficial,  as  two  or  three  grains  of  nitrate  of  silver,  or  of  alum  or 
tannin,  to  the  ounce  of  water.  It  should  be  borne  in  mind  that  washes 
for  the  nasal  surface  should,  as  a  rule,  be  employed  tepid. 


CHAPTER    II. 

CATARRHAL  LARYNGITIS. 

Acute  catarrhal  laryngitis  occurs  at  all  ages,  but  it  is  so  common  in 
infancy  and  childhood,  that  it  is  proper  to  treat  of  it  in  a  work  relating 
to  the  diseases  of  these  periods.  Like  other  inflammatory  affections  of 
the  air-passages,  it  is  most  common  in  the  cold  months,  or  when  the 
weather  is  changeable.  Its  usual  cause  is,  therefore,  exposure  to  cold. 
Protracted  and  violent  crying,  and  the  inhalation  of  acrid  vapors  are 
occasional  causes.  Catarrhal,  or  as  it  is  sometimes  designated  simple 
laryngitis,  also  occurs  in  connection  with  certain  constitutional  diseases, 
among  which  may  be  mentioned  measles,  scarlatina,  and  variola.  Laryn- 
gitis is  also  a  common  accompaniment  of  bronchitis,  and  not  infrequently 
of  pneumonitis,  though  its  symptoms  are  liable  to  be  obscured  by  those 
of  the  graver  disease.  It  often  likewise  accompanies  pharyngitis,  due 
to  extension  of  the  inflammation. 

Symptoms. — Catarrhal  laryngitis  produced  by  the  impression  of  cold, 
is  commonly  preceded  and  accompanied  by  coryza.  The  initial  symp- 
tom is  chilliness,  followed  by  sneezing,  and  the  discharge  of  thin  mucus 
from  the  nostrils  in  consequence  of  irritation  of  the  Schneiderian  mem- 
brane. 

The  commencement  of  laryngitis  is  indicated  by  hoarseness,  Avhich  is 
apparent  when  the  child  cries,  or,  if  old  enough,  when  it  attempts  to 
speak.  There  is  often  in  severe  cases  complete  loss  of  voice,  so  that 
speech  above  a  whisper  is  impossible.  I  have  noticed  this  most  fre- 
quently in  the  laryngitis  which  accompanies  measles.     A  cough  occurs 


560  CATARKHAL    LARYNGITIS. 

wliich  is  at  first  dry  and  husky  but  becomes  loose  in  the  course  of  a  few 
days.  Expectoration  is  scanty,  unless  the  intianniiation  have  extended 
to  the  trachea  and  bronchial  tubes. 

This  disease  is  often  accompanied  by  soreness  of  the  throat,  noticed 
in  the  act  of  coughing  or  when  the  larynx  is  pressed  with  the  finger. 
In  hiryngeal  catarrh,  Avhen  uncomplicated,  the  respiration  remains 
nearly  natural  and  the  pulse  is  but  little  accelerated.  In  mikl  cases  the 
nature  of  the  disease  is  often  not  ai)parent  as  long  as  the  child  remains 
quiet,  in  consequence  of  the  absence  of  symptoms,  but  tlie  character  of 
the  voice  Avhen  it  cries  or  s])eaks,  or  of  the  cough,  reveals  at  once  the 
nature  of  the  affection. 

Acute  laryngeal  catarrh  subsides  in  from  one  to  two  weeks.  Occa- 
sionally it  lasts  three  or  four  weeks  before  the  symptoms  entirely  dis- 
a^jpear.      Death,  which  is  rare,  is  due  to  some  complication. 

Chronic  laryngitis  is  much  less  frequent  than  the  acute  form.  Its 
anatomical  characters  are  similar  to  those  in  other  chronic  inflamma- 
tions affecting  mucous  surfaces,  to  wit.  thickening  and  more  or  less  in- 
filtration of  the  mucous  membrane,  increased  proliferation  and  exfoliation 
of  the  epithelial  cells,  and  increased  functional  activity  of  the  muciparous 
follicles. 

In  the  a<lult,  chronic  laryngitis  is  common  as  one  of  the  lesions  of  the 
syphilitic  or  tubercular  disease.  In  the  child  syphilitic  and  tubercular 
laryngitis  is  more  rare,  but  the  latter  sometimes  occurs  in  connection 
witli  pulmonary  or  bronchial  tuberculosis.  Such  patients  are  emaciated, 
and  have  the  ordinary  symptoms  of  the  tubercular  disease.  Chronic 
laryngitis  also  occurs  in  young  children,  usually  inf^mts,  as  one  of  the 
manifestations  of  the  strumous  diathesis.  I  have  records  of  several  such 
cases,  mostly  nursing  infants.  Some  of  these  patients  had  mild  bron- 
chitis, but  it  was  obviously  subordinate  to  the  laryngitis.  Their  respira- 
tion was  noisy  and  harsh,  continuing  of  this  character  for  several  weeks 
and  even  montlis.  The  cough  was  also  harsh  and  loud,  conveying  the 
idea  of  thickening  and  relaxation  of  the  mucous  membrane  covering  the 
vocal  cords.  Their  respiration  was  not  notably  accelerated,  and  the 
blood  was  apparently  fully  oxygenated,  though  the  friends  were  often 
alarmed  by  the  noisy  breathing  and  cough. 

In  this  form  of  chronic  laryngitis  expectoration  is  scanty,  the  fever 
slight  or  absent,  the  appetite  remains  unimpaired,  and  the  general  con- 
dition of  the  child  is  good.  From  time  to  time  exacerbations  occur, 
and  occasionally  improvement  is  such  as  to  encourage  the  hope  of  speedy 
cure,  but  in  the  cases  which  I  have  seen  there  has  not  been  complete 
intermission  in  the  disease  till  the  final  recovery.  Those  patients  whom 
I  have  been  able  to  follow  through  the  disease  have  recovered  in  from 
three  or  four  months  to  one  year. 

Chronic  laryngitis  is  to  be  distinguished  from  frequent  attacks  of 
acute  laryngitis,  which  are  due  to  fresh  exposures,  and  also  from  the 
laryngitis  which  is  associated  with  bronchial  phthisis.  It  is  to  be  dis- 
tinguished from  protracted  acute  laryngitis,  which  sometimes  does  not 
entirely  subside  in  less  than  a  month  or  six  weeks,  by  its  longer  dura- 
tion, tiie  greater  thickening  of  the  inflamed  membrane,  and  more  noisy 
respiration.     Often  chronic   laryngitis  results  from  the  acute  disease, 


TREATMEXT.  561 

the  inflammation  being  perpetuated  by  the  struma  or  dyscrasia  of  the 
patients. 

AxATOMicAL  Characters, — In  acute  catarrhal  laryngitis  the  mucous 
membrane  of  the  larynx  presents  the  usual  appearances  of  mucous  sur- 
faces when  inflamed,  namely,  redness  and  thickening.  It  is  also  more 
or  less  softened.  Ulcerations  rarely,  perhaps  never,  occur  in  primary 
acute  laryngitis.  When  present  in  chronic  laryngitis,  the  ulcers  are 
small  and  situated  upon  or  near  the  vocal  cords.  Tubercular  and  syphi- 
litic ulcers  of  the  larynx  are  much  more  rare  in  children  than  in  adults. 
The  inflammation  in  simple  acute  laryngitis  usually  extends  over  the 
whole  surface  of  the  larynx,  and  also  to  the  upper  part  of  the  trachea. 
It  may  be  pretty  uniform,  or  more  intense  in  one  place  than  another, 
and,  like  other  mucous  inflammations,  it  is  accompanied  by  more  or  less 
proliferation  and  exfoliation  of  epithelial  cells.  In  most  cases  of  simple 
laryngitis,  whether  acute  or  chronic,  the  inflammation  extends  to  the 
phar^'nx,  producing  redness  and  thickening,  though  generally  moderate, 
of  the  mucous  membrane  which  covers  it.  Examination  of  the  fauces 
therefoi'e  aids  in  diagnosis. 

In  the  adult  oedema  glottidis  occasionally  results  from  laryngitis.  In 
the  child  there  is  little  danger  that  this  will  occur,  in  consequence  of 
the  anatomical  character  of  the  larynx,  since  in  early  life  the  larynx 
contains  but  little  submucous  connective  tissue,  and  therefore  less  sub- 
mucous infiltration  or  eff"usion  occurs  during  the  inflammation.  The 
structural  changes  occurring  in  catarrhal  laryngitis  of  infancy  and  child- 
hood relate  almost  exclusively  to  the  mucous  membrane. 

Treatment. — Primary  and  uncomplicated  catarrhal  laryngitis  re- 
quires little  treatment.  Most  cases  do  well  by  the  employment  of 
suitable  hygienic  measures,  without  medicines.  Benefit  is,  however, 
derived  from  the  use  of  demulcent  drinks  and  an  occasional  laxative, 
A  mixture  of  paregoric  and  syrup  of  ipecacuanha,  or  the  mist,  glycyr, 
comp.,  or  a  small  Dover's  powder,  Avillrelieve  the  cough.  For  restless- 
ness, a  warm  foot-bath  is  also  useful.  Inhalation  of  the  spray  of  gly- 
cerine and  water  from  the  atomizer,  or  of  steam,  plain  or  medicated,  is 
also  useful.  Mildly  stimulating  embrocations,  as  by  camphorated  oil 
with  or  without  a  little  turpentine,  also  aid.  It  should  be  rubbed  sev- 
eral times  daily  over  the  throat,  or  a  strip  of  flannel  soaked  Avith  it  may 
be  applied  around  the  neck.  Chronic  laryngitis  dependent  on  syphilis 
or  tuberculosis  requires  the  constitutional  treatment  which  is  appropriate 
for  that  diseiKO.  .Measures  not  specific  have  little  eff'ect  upon  this  form 
of  inflammation.  The  chronic  laryngitis  wliich  I  have  described  as 
occurring  chiefly  in  infancy,  and  which  appears  to  be  of  a  strumous 
character,  is  in  most  cases  obstinate.  The  patient  should  be  Avarmly 
clothed,  and  constant  care  should  be  taken  that  there  be  no  exposure 
which  would  endanger  taking  cold,  as  this  would  produce  an  exacerba- 
tion of  tlie  disease,  and  tend  to  counteract  what  had  been  gained  by 
remedial  measures.  This  form  of  chronic  laryngitis  is  most  satisfacto- 
rily treated  by  the  application  of  tincture  of  iodine  upon  the  neck, 
directly  over  the  larynx,  and  the  internal  use  of  cod-liver  oil  and  the 
syrup  of  tlie  iodide  of  iron.  No  benefit  results  in  this  inflammation 
from  expectorant  remedies,  as  squills  or  senega. 

8G 


562  SPASMODIC    LARYNGITIS. 


Spasmodic  Laryngitis. 

This  is  a  common  disease.  It  is  also  called  fiilse  croup,  in  contra- 
distinction to  true  or  jjseudo-membranous  croup,  and,  by  some  conti- 
nental "writers,  stridulous  angina  or  stridulous  laryngitis.  It  should 
not  be  confounded  with  spasm  of  the  glottis,  which  is  a  form  of  inter- 
nal convulsions,  and  is  not  inflammatory.  It  occurs  ordinarily  between 
the  ages  of  two  and  five  years.  It  is  commonly  a  sporadic  affection, 
but  Killiet  and  Barthez  state  that  "  it  is  incontestable  that  it  may  pre- 
vail epidemically."  They  express  this  opinion,  not  from  their  own 
observations,  but  chiefly  from  those  of  Jurine,  made  in  the  commence- 
ment of  the  present  century. 

Causes. — Children  in  some  families  are  more  liable  to  false  croup 
than  in  others,  so  that  an  hereditary  tendency  to  it  must  be  admitted. 
The  exciting  cause  in  most  cases  is  exposure  to  cold.  False  croup  is 
not  unconnnon  in  the  commencement  of  measles.  Narrowness  of  the 
rima  glottidis,  and  an  excitable  state  of  the  nervous  system,  both  of 
which  are  common  in  early  childhood,  are  predisposing  causes. 

Symptoms. — Spasmodic  laryngitis  is  ordinarily  preceded  for  a  day  or 
two  by  a  slight  cough  and  fever,  by  symptoms  of  mild  nasal  catarrh, 
such  as  all  children  are  liable  to  on  taking  cold.  In  exce])tional  cases 
these  symptoms  are  absent  and  the  disease  begins  abruptly.  Singu- 
larly, it  commences  in  most  patients  at  night,  after  the  first  sleep,  be- 
tAveen  ten  and  twelve  o'clock.  The  sleep  is  usually  quiet  and  natural, 
but  the  child  awakens  with  a  loud,  barking  cough.  There  is  great 
dyspncea,  and  the  respiration  is  harsh  or  whistling,  on  account  of  the 
narrowing  of  the  chink  of  the  glottis  from  the  swelling  and  tension  of 
the  vocal  cords.  The  face  is  flushed  and  expressive  o£  suffering.  The 
child  cries,  moves  from  one  position  to  another,  wishes  to  be  held  or 
carried,  seeking  in  vain  for  relief.  The  skin  is  hot,  pulse  accelerated, 
the  voice  hoarse  or  even  whispering.  After  a  variable  period,  usually 
from  half  an  hour  to  two  or  three — not  more  than  half  an  hour  Avith 
proper  treatment — these  symptoms  abate.  The  patient  is  then  sorae- 
Avhat  exhausted  and  falls  asleep.  The  face  is  less  flushed  or  even  pallid, 
the  heat  abates,  and  the  pulse  is  less  accelerated.  The  cough,  though 
less  frequent,  remains  for  a  time  barking  or  sonorous,  and  respiration, 
though  greatly  relieved,  is  not  at  once  entirely  natural,  but  it  gradually 
becomes  so.  In  many  cases  the  spasmodic  respiration  and  cough  do 
not  recur,  but  sometimes  the  attack  is  repeated  once  or  more,  especially 
during  the  subsecjuent  nights.  The  symptoms  A'ary  greatly  in  intensity 
in  different  patients. 

As  the  attack  declines,  the  disease,  losing  its  spasmodic  character, 
becomes  a  simple  inflammation.  In  some  patients  the  abatement  of  the 
cough  and  restoration  of  health  are  rapid,  but  oftener  the  inflammation 
extends  not  only  into  the  trachea,  but  also  into  the  larger  bronchial 
tubes,  and  a  tracheo-bronchitis  remains,  Avhich  gradually  declines. 

The  termination  is  not  ahvays  so  favorable.  Spasmodic  laryngitis  is. 
in  exceptional  instances,  the  precursor  of  other  serious  affections,  Avhich 
may  prove  fatal.     It  has  been  stated  that  measles  often  begins  with 


^DIAGNOSIS.  563 

spasmodic  laryngitis.  Bronchitis  becoming  capillary,  may  occur  iv 
connection  with  it,  as  may  also  pneumonia,  and  by  either  of  these 
severe  inflammations  the  prognosis  may  be  rendered  doubtful.  A  few 
cases  have  been  recorded  in  which  it  was  believed  that  spasmodic  laryn- 
gitis was  of  itself  fatal.  In  some  of  these  the  dyspncea  was  extreme 
and  persistent,  and  was  the  cause  of  death.  In  a  case  reported  by 
Rogery,  on  the  other  hand,  the  respiration  became  easy  before  death, 
and  the  pulse  more  and  more  frequent  and  feeble.  Death  apparently 
occurred  from  exhaustion.  It  is  not  improbable  that,  had  careful  post- 
mortem examinations  been  made  in  those  cases  of  spasmodic  laryngitis 
which  have  en«lcd  fxtally,  other  lesions  would  have  been  discovered  be- 
sides those  located  in  the  larynx,  perhaps  tracheo-bronchitis,  with  an 
accumulation  of  mucus  in  the  larynx,  producing  suftbcation,  or  perhaps 
in  some  of  the  cases  congestion  of  the  brain  or  lungs  and  serous  eifusion. 

Anatomical  Characters — Pathology. — The  opportunity  does  not 
often  occur  of  determining  the  anatomical  characters  of  spasmodic  laryn- 
gitis. I  have  witnessed  but  one  post-mortem  examination,  A  little 
girl,  nine  years  old,  was  taken  on  Friday  night  with  cough  and  dys- 
pnoea, indicating  a  pretty  severe  attack.  The  mother,  acting  through 
the  advice  of  a  friend,  gave  kerosene  oil  to  her  in  considerable  quantity. 
This  was  succeeded  by  obstinate  vomiting  and  purging,  which  continued 
during  Saturday  and  Sunday,  and  terminated  fatally  on  Monday.  At 
the  autopsy  we  found  uniform  and  intense  injection  throughout  the 
Avliole  extent  of  the  larynx  and  trachea  and  in  the  broncliial  tubes,  but 
there  was  no  pseudo-membrane  on  the  inflamed  surfiee,  and  but  little 
mucus  and  pus.  The  solitary  follicles  of  the  intestines  and  Peyer's 
patches  were  tumefied,  and  the  gastro-intestinal  surface  was  injected  in 
places.  The  cause  of  death  was  obviously  the  diarrhoea,  apparently  of 
an  inflammatory  character,  and  probably  produced  by  the  kerosene  oil. 
The  condition  of  the  mucous  membrane  of  the  larynx  was  that  which  is 
ordinarily  present  in  spasmodic  laryngitis,  though  in  some  cases  in 
which  post-mortem  examinations  have  been  made  the  evidences  of  laryn- 
geal inflammation  were  slight.  Guersant  relates  a  case  in  which  the 
surface  of  the  larynx  seemed  to  be  nearly  in  its  normal  state.  Death 
in  cases  of  slight  laryngitis  is  due  to  causes  which  are  independent  of 
the  larynx.      In  (ruersants  case  tubercidosis  Avas  present. 

There  is,  as  has  already  been  intimated,  another  and  a  more  important 
element  besides  the  inflammation  in  the  pathology  of  spasmodic  laryn- 
gitis— an  element  producing  those  phenomena  which  render  it  a  disease 
distinct  from  simple  laryngitis.  I  refer  to  spasm  of  the  laryngeal  mus- 
cles. This  element  pertains  to  the  nervous  system,  so  that  spasmodic 
laryngitis  is  allied  both  to  the  neuroses  and  to  inflammation. 

l)iAGNOr;is. — The  disease  ff)r  which  spasmodic  laryngitis  is  most  fre- 
quently mistaken  is  pseudo-membranous  croup.  The  friends,  indeed, 
usually  make  this  mistake  in  forming  their  opinion  of  the  case  before 
the  physician  arrives;  and  there  can  be  no  doubt  that  many  of  the 
cases  which  have  been  ])nblishe(l  in  medical  journals  as  true  croup 
were  exam|)les  of  this  affection.  The  points  of  dift'erentiid  diagiu^sis 
are  the  following  :  True  cr<»u])  begins  with  synijitoms  which  ;it  first  are 
slight,  so  as  scarcely  to  arrest  attention,  but  which  gradiinlly  increa.se 


56-i  SPASMODIC    LARYNGITIS. 

in  intensity.  The  cough  becomes  more  harsh,  and  the  respiration  more 
difficult,  by  degrees.  This  increase  in  the  gravity  of  tlio  symptoms 
occurs  by  day  as  "svell  as  by  night.  On  the  other  hand,  false  croup, 
though  preceded  by  symptoms  of  nasal  catarrh,  commences  abruptly. 
The  symptoms  have  from  the  first  their  maximum  intensity,  and  the 
time  at  Avhich  it  commences  is  at  night.  Again,  the  cough  in  spas- 
modic laryngitis  possesses  a  loud,  sonorous  character  ;  Avhile  in  true 
croup  it  is  harsh  or  rough,  from  the  presence  of  the  mcndn-ane,  and 
having,  therefore,  less  fulness.  The  voice  in  spasmodic  laryngitis  may 
be  hoarse,  but  it  is  not  lost,  or  is  lost  only  for  a  short  time.  It  after- 
Avard  becomes  natural,  or  is  slightly  hoarse.  On  the  other  hand,  in 
true  croup,  the  voice,  from  being  natural  at  first,  is  gradually  extin- 
guished. In  fatal  cases  it  soon  becomes  -whispering,  and  continues  such 
till  the  close  of  life;  in  those  that  recover,  the  voice  remains  hoarse  for 
several  days.  These  difterences  are  important,  and,  if  fully  appreciated, 
are  in  most  instances  sufficient  to  establish  the  diagnosis.  Besides,  in  a 
large  proportion  of  eases  of  true  croup,  portions  of  the  pseudo-membrane 
may  be  discovered  on  inspecting  the  fauces,  and  the  fiiucial  surface  is 
deeply  injected,  while  in  spasmodic  laryngitis  there  is,  Avith  rare  excep- 
tions, no  false  memljrane  upon  the  surface  of  tlie  fauces,  and  but  a  mod- 
erate amount  of  congestion. 

Laryngismus  stridulus,  or  internal  convulsions,  must  not  be  con- 
founded Avith  this  disease.  It  is  not  inflammatory,  but  purely  spas- 
modic, suddenly  commencing  and  abating — identical,  it  is  believed,  in 
character  Avith  tonic  convulsions  of  the  external  muscles,  but  aflecting 
the  internal  muscles  of  respiration.  T^his  disease  has  already  been  fully 
described. 

Prognosis. — Little  need  be  added,  as  regards  prognosis,  to  Avhat  has 
already  been  stated.  While  a  favorable  opinion  in  reference  to  the 
result  may  ordinarily  be  expressed,  the  physician  should  not  forget  the 
fact  that  death  may  occur.  Symptoms  indicating  an  unfavorable  termi- 
nation arc  :  great  and  continued  dyspnoea,  not  diminished  by  the  proper 
remedial  measures  ;  stridulous  expiration  as  Avell  as  inspiration  ;  lividity 
of  the  prolaljia  and  fingers ;  pallor  and  coldness  of  surface  ;  pulse  pro- 
gressively more  frequent  and  feeble.  Convulsions  and  coma  may  also 
occur  near  the  close  of  life. 

Treatment. — The  indications  of  treatment  are  tAvofold :  first,  to 
relieve  the  spasmodic  action  of  the  laryngeal  muscles;  secondly,  to  cure 
the  laryngitis.  To  meet  the  first  indication,  a  Avarm  bath  of  the  tem- 
perature of  about  100°  should  be  employed  as  soon  as  possible  after  the 
commencement  of  the  attack.  The  patient  should  be  kept  in  it  ten  or 
fifteen  minutes,  in  order  to  obtain  its  full  relaxing  effect.  In  mild  cases 
a  Avarm  foot-bath  may  l)e  sufficient.  A  second  means  is  the  use  of  an 
emetic,  Avhich  should  be  simultaneous  Avith  the  bath.  To  children  under 
the  age  of  three  years,  syrup  of  ipecacuanha  should  be  given,  in  doses 
of  one  teaspoonful,  repeated  in  tAventy  minutes,  till  vomiting  occurs;  or 
alum  and  syrup  of  ipecacuanha,  tAvo  drachms  of  the  former  to  one  ounce 
of  the  latter,  may  be  given  in  the  same  dose.  The  alum  and  the  syrup 
produce  more  prompt  emesis  than  the  syrup  alone.  Children  over  the 
age  of  three  years,  unless  of  feeble  constitutions,  are  best  treated  by  the 


TREATMEXT.  565 

compound  syrup  of  squills  in  teaspoonful  doses,  or  a  mixture  of  tliis 
with  syrup  of  ipecacuanha.  It  is  not  often  necessary  to  give  more  than 
three  or  four  doses,  and  sometimes  one  or  two  are  sufficient  to  produce 
vomiting. 

In  most  cases,  by  the  use  of  the  warm  bath  and  the  emetic,  the  symp- 
toms are  rendered  milder,  and  convalescence  soon  commences. 

Dr.  R.  R.  Livingstone^  reports  a  case  of  laryngitis  treated  by  Squibb's 
ether.  It  is  stated  that  portions  of  pseudo-membrane,  from  one-eighth 
to  three-fourths  of  an  inch  in  length,  were  expectoi'ated ;  but  the  symp- 
toms certainly  indicated  a  spasmodic  element  as  decidevl  as  in  spasmodic 
croup,  and  the  benefit  from  the  ether  was  apparently  due  to  the  relaxa- 
tion of  the  laryngeal  muscles  wliicli  it  produced.  The  treatment  of  the 
patient,  who  was  two  years  old,  was  commenced  by  the  administration 
by  the  mouth  of  half  a  teaspoonful  of  the  ether,  and  followed  by  its  inha- 
lation. "  In  precisely  eight  minutes  from  the  time  the  patient  com- 
menced the  inhalation,  the  abnormal  muscular  exertion  ceased ;  a  gen- 
eral relaxation  took  place;  the  pulse  (which  had  numbered  150)  fell  to 
100.''  Ether,  judiciously  employed,  will  probably  prove  to  be  a  useful 
remedial  agent  in  spasmodic  forms  of  laryngitis,  whether  or  not  it  have 
any  effect  on  pseudo-membranous  formations.  A  large  majority  of 
cases,  however,  recover,  speedily  without  its  employment,  or  by  the 
other  measures  recommended. 

Attention  should  always  be  given  to  the  state  of  the  bowels  in  spas- 
modic laryngitis;  if  they  are  not  well' open,  a  purgative  should  be  ad- 
ministered. For  those  that  are  robust,  and  with  considerable  febrile 
movement,  the  saline  cathartics  are  ordinarily  preferable,  as  Rochelle 
salts,  or  a  purgative  dose  of  calomel  may  be  administered.  The  cathartic 
should  not  be  prescribed  till  the  nausea  fi-om  the  emetic  has  subsided. 
By  its  derivative  effect,  it  tcmls  to  diminish  the  laryngitis,  and,  in  severe 
cases,  it  may  obviate  the  neccl  of  depletion  by  leeches. 

Inhalation  of  the  vapor  of  hot  water,  and  the  a])plication  of  a  sinapism 
over  the  neck  and  upper  part  of  tlie  sternum,  followed  by  an  emollient 
poultice,  are  useful  adjuvants  to  treatment. 

The  most  convenient  and  effectual  way  of  employing  vapor  is,  how- 
ever, by  the  atomizer,  and  as  the  ciiief  danger  is  that  the  inflammation 
may  become  pseudo-memljranous,  I  am  in  the  habit  of  using  in  the 
atomizer  the  officinal  lime-water. 

When  the  spasmodic  element  in  the  disease  is  relieved,  the  case  be- 
comes one  of  simple  laryngitis,  and  the  general  plan  of  treatment  recom- 
mended for  tliat  malady  is  ])roper  for  this.  Small  doses  of  ipecacuanha, 
or  of  one  of  the  aiitimonial  j)reparations,  as  the  com|)ound  syrup  of 
squills,  not  sufficient  to  cause  nausea,  should  now  be  given  at  regular 
intervals.  I  have  sometimes  added  to  the  expectorant  one  droj)  of  the 
tincture  of  aconite  root  for  robust  children  over  the  age  of  three  or  four 
years,  having  a  full  and  rapid  pulse,  flushed  face,  and  other  evidences 
of  active  febrile  movement.  Its  effect  should  be  watched,  and  it  should 
be  discontinued  when  its  sedative  influence  on  the  circulation  begins  to 

1  Aiuciican  Juurnul  of  the  ilcdiLul  Science-,  April,  18G7. 


566  SPASMODIC    LAKYXGITIS. 

be  apparent.  It  should  not  be  given  in  the  spasmodic  laryngitis  which 
occurs  in  the  commencement  of  measles. 

If,  however,  the  disease  do  not  speedily  terminate  by  recover}^  of  the 
patient,  or,  more  rarely,  by  death,  there  is  nearly  always  tracheo-bron- 
chitis,  or  a  more  serious  affection,  coexisting  with  the  laryngitis,  or 
following  it,  so  that  depressing  measures  should  not  be  long  continued. 
Expectorants  of  a  stimulating  character,  as  carbonate  of  ammonium,  or 
syrup  of  senega,  are  required  in  the  course  of  a  few  days,  and  in  young 
and  feeble  children  they  should  be  given  at  an  early  period. 

The  mode  of  treatment  recommended  above  is  apjn-opriatc  for  that 
large  class  in  whom  the  inllaunnatory  eleuient  predominates.  In  a 
smaller  number  of  cases  the  nervous  element  predominates  over  the 
inflammatory,  and  the  treatment  should  be  in  some  respects  different. 
Sucli  children  are  usually  pallid  and  of  spare  habit,  having,  indeed,  the 
nervous  tem[)eranient.  They  are  liable  to  attacks  of  this  disease,  though 
generally  of  a  mild  form,  on  slight  exposure  to  cold,  and  with  a  very 
moderate  amount  of  inflammation.  The  treatment  in  these  cases  should 
be  directed  more  to  the  nervous  system.  My  plan  has  been,  in  the 
treatment  of  such  patients,  after  perhaps  the  use  of  a  mild  emetic,  to 
give  cpiinine,  one  grain  three  or  four  times  daily,  to  a  child  from  three 
to  five  years  old,  i)rescribing  at  the  same  time  a  simple  ex})ectorant,  as 
svrup  of  s(piills,  and  a  mildly  irritating  application  to  the  throat.  The 
symptoms  in  these  cases  are  not  severe,  and  active  measures  are  not 
re(iuired,  though  the  peculiar  cough  continues  longer  than  in  the  more 
inflammatory  forms  of  the  malady. 

The  patient  with  spasmodic  laryngitis  should  be  kept  in  a  warm 
room  during  the  paroxysms,  and  should  inhale  an  atmosphere  loaded 
Avith  moisture. 

Trousseau  recommends  a  mode  of  treatment  of  spasmodic  laryngitis 
which  was  first  suggested  by  Graves,  of  Dublin.  It  consists  in  the 
application  underneath  the  chin,  so  as  to  cover  the  larynx,  of  a  sponge 
soaked  in  water  as  hot  as  can  be  borne ;  in  ten  or  fifteen  nn'nutes  it  is 
repeated.  This  reddens-  the  skin,  })roducing  revulsion  from  the  larynx. 
The  hoarseness,  dyspnoea,  and  cough  diminish  with  this  treatment,  and 
some  recover  without  other  ineasures. 

Guersant  and  others  speak  of  the  importance  of  prophylactic  man- 
ao-ement  of  children  who  are  liable  to  this  disease.  Attention  should 
be  given  to  the  dress,  so  that  there  may  be  sufficient  protection  from 
atmospheric  changes,  and  there  should  bean  equable  temperature  of  the 
apartments  in  which  they  reside.  Children  of  a  decidedly  nervous  tem- 
])erament,  in  whom  the  slightest  laryngitis  is  liable  to  be  spasmodic,  re- 
quire additional  prophylactic  measures.  They  are  pallid,  and  in  a  more 
or  less  cachectic  state.  Such  children  are  benefited  by  chalybeate  and 
vegetable  tonics,  and  by  exercise  in  suitable  weather  in  the  open  air. 


MEMBRANOUS    CROUP.  567 


CHAPTER  III. 

MEilBEAXOUS  CKOUP;  DIPHTHEKITIC  CROUP;  TRUE  CROUP. 

The  term  pseudo-membranous  laryngitis,  or  laryngo-tracheitis,  or 
true  croup,  is  a})plied  to  a  common  and  fatal  disease,  the  essential  ana- 
tomical character  of  wliicli  is  inflammation  of  the  larynx,  or  larynx  and 
trachea,  with  the  formation  of  a  pseudo-membrane  upon  its  surface.  It 
occurs  most  frequently  between  the  ages  of  two  and  twelve  years,  but 
infancy  after  the  age  of  six  months  and  early  manhood  are  not  exempt 
from  it.  For  brevity  I  shall  use  the  term  croup  in  the  following  pages 
to  indicate  this  form  of  inflammation,  although  recognizing  another  form 
of  croup,  the  spasmodic  or  catarrhal,  in  which  no  pseudo-membrane 
occurs. 

Etiology. — Wherever  diphtheria  prevails  as  an  endemic  or  epidemic, 
it  is  well  known  that  a  large  majority  of  the  cases  of  membranous  croup 
are  local  manifestations  of  this  disease,  and  this  inflammation  is  there- 
fore in  such  localities  commonly  designated  diphtheritic  croup.  Physi- 
cians have  endeavored  to  discriminate  between  croup  due  to  diphtheria 
and  that  from  other  causes ;  but  whatever  the  cause,  the  anatomical 
characters,  the  clinical  history,  and  the  required  treatment  are  so  nearly 
identical  that  attempts  to  differentiate  the  disease  when  produced  by 
other  agencies  than  diphtheria  from  that  due  to  diphtheria,  have  proved 
futile  and  unsatisfactory  in  localities  where  diphtheria  occurs,  except  in 
a  few  instances,  as,  for  example,  when  croup  has  been  manifestly  caused 
by  swallowing  or  inhaling  some  irritating  agent. 

Inflammation  of  the  laryngeal  and  tracheal  surfice,  whatever  its 
cause,  whenever  it  reaches  a  certain  grade  of  severity,  may  be  attended 
by  the  exudation  of  fibrin  and  the  formation  of  a  pseudo-membrane,  but 
such  a  result  more  fre([uently  occurs  in  the  inflammation  caused  by 
diphtheria  than  in  that  produce<l  by  other  agencies.  In  diphtheria  a 
moderate  laryngo-tracheitis  is  attended  by  the  pseudo-membranous 
formation. 

The  percentage  of  cases  of  diphtheria  in  which  the  larynx  becomes 
implicated  and  croup  occurs,  varies  in  different  epidemics  and  in  dif- 
ferent seasons  and  localities.  In  epidemics  of  a  mihl  type,  the  cases 
ap))ear  to  be  fewer  in  whicli  the  hirynx  is  involved  than  in  epidemics 
of  a  severe  fu-m.  In  New  York  tlie  percentage  is  hirge.  From  De- 
cember 1,  1875,  to  July,  1878,  I  preserved  records  of  all  the  cases  of 
diphtheria  which  came  under  my  notice.  The  number  was  l')4,  and  in 
twenty-five  of  these,  or  about  one  in  four,  croup  occurred,  producing  the 
usual  obstructive  symptoms,  and  constituting  tiie  chief  source  of  danger. 
During  the  two  and  a  half  years  embraced  in  tiiese  statistics  the  disease 
was  usually  severe.  In  the  last  five  years  amelioration  has  occurred 
in  the  tyj)e  of  diphtheria  in  this  city,  and  the  proportion  of  croup  cases 
has  not  been  so  large. 


668 


M  E  -M  13  R  A  X  O  U  S    CROUP. 


So  commonly  is  membranous  croup,  "when  occurring  in  a  locality 
■where  dij^htheria  is  endemic  or  epidemic,  a  local  manifestation  of  diph- 
theria, that  physicians  in  such  localities  come  to  regard  every  case  of 
this  disease  of  the  larynx  as  produced  by  the  diphtheritic  poison.  In 
New  York  physicians  scarcely  recognize  any  other  form  of  membranous 
croup.  It  is  well,  therefore,  briefly  to  recall  the  evidences  that  croup 
in  a  certain  proportion  of  cases  results  from  other  causes  than  diph- 
theria. The  occurrence  of  croup  in  localities  Avhere  di])htheria  is  un- 
known, of  course,  indicates  the  operation  of  some  other  agency  than  the 
diphtheritic  poison.  Thus,  in  1842,  before  diplithcria  Avas  established 
in  this  country.  Dr.  John  Ware,  of  Boston,  ])ublished  his  well-known 
paper  on  croup,  and  in  74  of  the  75  cases  embraced  in  his  statistics  the 
membranous  exudation  was  present  upon  the  faucial  surface.  The  sta- 
tistics relating  to  the  introduction  of  diphtheria  into  New  York  City, 
and  the  recorded  death  statistics  of  this  city,  have  been  annually  pub- 
lished, and  each  year  more  or  fewer  deaths  from  croup  have  been  re- 
ported. The  first  death  from  diphtheria  in  this  century,  Avithin  the  city 
limits,  certified  by  a  physician,  was  that  of  a  German  woman,  at  638 
Hudson  Street,  on  February  15,  1852.  Tavo  other  fatal  cases  occurred 
in  1357,  and  since  then  the  deaths  from  croup  and  diphtheria  have  been 
as  shoAvn  in  the  folloAvino;  table : 


Tear 

1858 

1859 

18(iO 

1801 

1862 

1803 

18(U 

1865 

1866 


Croup. 

Dii)htheria, 

478 

5 

622 

53 

599 

422 

460 

453 

685 

594 

908 

981 

754 

781 

440 

534 

368 

435 

Tear. 

1867 
1868 
1869 
1870 
1871 
1872 
1873 
1874 
1875 


>oup. 

Diplitheria. 

838 

251 

342 

276 

483 

328 

421 

308 

466 

238 

675 

446 

732 

1151 

594 

1665 

758 

2329 

Since  1875  weekly  Lulletins  were  issued,  instead  of  the  annuiil  reports. 

Thus,  in  the  first  years  after  the  introduction  of  diphtheria,  the 
deaths  assigned  to  croup  so  greatly  outnumbered  those  of  diphtheria,  as 
in  1858,  Avhen  five  died  of  diphtheria  and  four  hundred  and  seventy- 
eio-ht  of  croup,  tliat  it  is  evident  that  most  of  the  cases  of  croup  in  those 
years  Avere  attributable  to  other  causes  than  diphtheria.  Since,  as  Ave 
have  stated,  any  inflammation  of  the  surface  of  the  larynx  and  trachea: 
if  sufficiently  intense,  may  produce  a  pseudo-membrane,  croup  may 
occur  as  a  primary  disease,  and  as  a  complication  of  A'arious  maladies. 
According  to  my  observations  in  New  York  City,  the  chief  causes  of 
croup,  arranged  in  the  order  of  frequency,  Avould  be  about  as  folloAvs  : 
diphtlieria,  "taking  cold,"  measles,  pertussis,  scarlatina,  typhoid  fever, 
irritating  inhalations.  I  have,  elscAvhere,  related  cases  of  scarlet  fcA^er 
of  scA'ere  type,  in  Avhich  a  thin  film  of  pseudo-membrane  Avas  found  upon 
the  surface  of  the  larynx  and  trachea,  and  there  Avas  no  other  lesion  to 
indicate  that  diphtheria  had  supervened.  Tlie  croup  Avas,  to  all  appear- 
ances, caused  by  the  scarlatinous  and  not  the  diphtheritic  poison.  The 
folloAvin'i-  Avas  a  case  in  Avliich  croup  Avas  apparently  idiopathic,  and  pro- 


ETIOLOGY.  5(59 

duced  bv  that  common  cause  of  inflammations  of  mucous  surfaces,  to 
Avit,  exposure  to  sudden  atmospheric  changes : 

Case. — At  midnight,  on  October  22,  1884,  I  Avas  summoned  to  a  child 
ao-ed  25  months,  who  had  been  in  the  sti'eet  till  nearly  nightfall,  when  the 
weather  suddenly  became  much  cooler,  and  he  was  briKight  home.  At 
11.45  p.  M.  he  awoke  with  a  harsh  voice  and  croupy  cough  so  as  to  alarm 
the  family.  I  found  the  axillary  temperature  normal,  but  the  fauces  were 
injected,  and  the  diagnosis  was  made  of  spasmodic  or  catarrhal  croup. 
Emesis  was  produced  by  syrup  of  ipecacuanha  ;  the  croup  kettle,  and  a 
mixture  of  potassium  chlorate  and  ammonium  chloride  were  ordered. 

On  the  following  day  he  walked  around  the  room  and  seemed  better, 
but  the  inhalation  of  the  vapor  of  lime  from  the  croup  kettle  was  con- 
tinued. At  7  p.  M.  the  symptoms  l)ecame  aggravated,  the  cough  was  fre- 
quent and  hoarse,  temperature  (axillary)  lOO^®,  pulse  120,  and  respiration 
noisy.  At  my  visit  the  post-clavicular,  supra-sternal,  infra-maiumary, 
and  epigastric  regions  were  de]iressed  in  each  inspiration,  tliough  only  to 
a  moderate  degree ;  face  flushed,  fauces  injected  but  without  pseudo-mem- 
brane. The  aspect  was  now  more  serious  on  account  of  the  increasing  dys- 
pnoea. The  pulse  was  strong,  and  no  pseudo-membrane  was  visible ;  the 
temperature  in  the  groin  was  scarcely  100^.  Emesis  had  been  produced 
before  mv  arrival,  and  in'  the  matter  vomited  was  a  pseudo-mend)rane 
with  ragged  edges,  and  about  one-half  an  inch  in  length;  examined  within 
an  hour  subseijuently  under  the  microscope,  it  was  found  to  consist  of 
fibril Ite,  evidently  fibrinous,  some  of  them  wavy,  and  inclosing  many  pus- 
cells.  Ten  grains  of  calomel  were  placed  on  the  tongue,  and  inlialations  of 
the  following  were  almost  constantly  employed  by  the  steam  atomizer: 

R. — Liq.  potassiB  .......      ^ 'i 

Aq.  calcis 5^^]- — -^Ii?ce. 

On  the  following  day  the  respiration  was  easier,  and  within  twenty 
hours  the  patient  had  so  far  convalesced  as  to  be  out  of  danger.  There 
had  l>een  no  case  of  diphtheria  in  the  house,  nor  recently,  so  far  as  I  could 
learn,  in  the  immediate  neighborhood. 

That  this  was  a  local  disease,  non-specific,  and  quite  distinct  from 
the  croup  of  diphtheria,  cannot,  I  think,  be  doubted. 

In  considering  the  etiology  of  croup,  and  recognizing  diphtheria  as 
by  far  its  most  common  cause,  wherever  the  latter  disease  prevails,  an 
interesting  theory  is  suggested,  to  which  Ilcubner  alludes,  wlio  affirms 
that  inflammations,  even  witli  the  characteristic  membranous  cxiulation, 
may  be  set  up  without  the  micrococci  of  diphtheria  and  then  inoculation 
by  micrococci  occur,  and  "  induce  the  general  disease."^  The  point 
alluded  to  is  that  inflammations  arising  from  other  causes  than  diphtheria 
now  and  then  become  intensified,  and  rendered  more  protracted  and  dan- 
gerous ))y  the  reception  of  the  diphtheritic  virus  after  the  inllammations 
are  cstal)lished.  In  su|)j)ort  of  this  opinion  it  is  well  known  by  all  who 
have  had  much  experience  with  diphtheria,  that  those  surfaces  are 
})rone  to  be  attacked  by  the  specific  inflammation  that  are  already  irri- 

'  "  Die  expcrimentellc  Dipliihoria,"  Leipzig,  188!?,  quoted  in  Zicglcr's  ratlioL 
Anut.,  part,  ii.,  paragraph  414,  Win.  Wood  &  Co.,  1884. 


570  MEMBRANOUS   CROUP. 

tated  or  inflamed  when  diphtheria  is  contracted.  Hence  the  occurrence 
of  the  pseudo-membrane  on  recent  wounds,  upon  the  eyelids  in  cases  of 
catarrhal  conjunctivitis,  upon  the  uterine  surftice  after  parturition,  and 
upon  the  laryngeal,  tracheal,  and  bronchial  surfaces,  if  they  are  already 
inflamed  as  in  measles. 

Scarlatina  is  so  often  complicated  by  diphtheria  that  there  seems  to 
be  a  close  affinity  between  the  two  diseases.  It  is  a  very  common  ob- 
servation in  New  York  City  that  scarlet  fever  continues  two  or  three 
days,  in  its  usual  form,  when  the  symptoms  become  suddenly  aggra- 
vated and  the  aspect  of  the  disease  more  severe.  On  inspecting  the 
fauces  a  pseudo-membrane  is  discovered  covering  this  region,  and  it 
probably  appears  also  upon  the  nasal  surface.  Although  severe  scarla- 
tinous inflammation  may  cause  a  fibrinous  exudation,  yet  that  diph- 
theria has  supervened  upon  scarlet  fever  in  a  considerable  proportion 
of  cases  which  have  the  above  history  cannot,  I  think,  be  doubted.  In 
a  few  instances  in  my  practice  (four)  the  fact  that  scarlet  fever  was  com- 
plicated by  true  diphtheria,  and  the  scarlatinous  inflammations,  first  in 
order,  were  intensified  by  the  presence  and  influence  of  the  diphtheritic 
poison,  Avas  shown  by  the  occurrence  of  diphtheria  without  scarlet  fever 
in  other  members  of  the  family. 

In  accordance  with  the  above  law,  we  may  assume  that  a  child  who 
has  laryngo-tracheitis,  so  common  from  taking  cold  and  manifested  by 
cough  and  hoarseness,  is  more  prone  to  have  diphtheritic  croup  than  is 
one  Avhose  air-passages  are  in  their  normal  state  when  diphtheria  com- 
mences. A  supposed  error  of  diagnosis  is  often  made  by  physicians, 
always  to  their  discredit,  who  diagnosticate  catarrhal  laryngitis,  but  find, 
after  two  or  three  days,  that  their  patients  really  have  diphtheritic 
croup.  A  consideraljle  number  of  such  instances  have  come  to  my 
notice,  ahvays  with  the  ill-will  of  families  toward  their  ])hysicians. 
Now  it  seems  to  me  that  in  many  of  these  cases  the  physicians  liave 
been  right  in  their  first  diagnosis,  and  diphtheritic  croup  supervened  on 
the  catarrhal  inflammation. 

Another  point  relating  to  the  etiology  of  diphtheritic  croup  requires 
notice.  Many  physicians,  who  have  had  ample  opportunities  to  ob- 
serve diphtheria,  believe  that  the  common  way  in  which  diphtheritic 
croup  begins  is  as  follows :  The  faucial  or  nasal  surface  is  first  aff"ected, 
becoming  covered  by  the  pellicular  exudation,  and  during  inspiration 
particles  of  the  pseudo-membrane,  containing  the  specific  principle,  being 
detached,  lodge  in  the  larynx.  At  the  point  of  inoculation  the  specific 
inflammation  arises  and  extends.  This  may  be  the  manner  in  which 
the  croup  of  diphtheria  begins  in  certain  cases,  but  it  certainly  does 
not  apply  to  a  considerable  number  of  patients.  Thus  botli  tlie  faucial 
and  nasal  pseudo-membranes  may  be  treated  every  second  or  third  hour 
from  the  time  of  their  formation  with  the  best  disinfectants  which  we 
possess,  so  as  to  destroy  all  the  micrococci  in  them  and  render  tliem  an 
inert  mass,  and  yet  croup  not  infrequently  occurs  during  the  progress 
of  the  case.  .Vgain,  in  certain  cases  croup  begins  at  the  commence- 
ment of  tiie  diphtheritic  attack.  Tlie  laryngitis  commences  as  early  as 
the  pharyngitis,  and  therefore  does  not  result  from  it.  Sometimes  the 
inflammation  of  the  air-passages  is   from   the  first   the    predominant 


AXATOMICAL    CHARACTERS.  571 

lesion,  the  pharyngitis  being  subordinate  or  even  trivial.  Thus  a  boy 
of"  two  years  ten  months,  whom  I  attended,  died  of  croup  lasting  about 
four  days.  He  lived  in  the  suburbs  of  the  city,  where  the  houses  Avere 
scattered,  and  where  there  had  been  no  recent  diphtheria.  The  attack 
began  with  hoarseness,  which  gradually  increased  to  a  fatal  obstruction 
in  the  air-passages.  Close  and  repeated  inspection  of  the  fouces  re- 
vealed only  redness  and  some  swelling  of  the  parts  that  were  visible, 
and  the  symptoms  indicated  but  slight  coryza.  The  diphtheritic  nature 
of  the  disease  was  rendered  certain  by  the  occurrence  of  diphtheria  in 
its  usual  form,  in  the  two  nurses  immediately  after  the  death  of  the 
child.  In  this  case  croup  began  at  the  beginning  of  the  sickness,  and 
it  is  evident  from  the  histoiT  and  the  lesions  that  the  contagium  was 
not  transferred  to  the  larynx  from  any  of  the  other  surfaces.  In  view 
of  the  number  of  such  cases,  I  see  no  propriety  in  assigning  to  diphthe- 
ritic croup  a  mode  of  origin  different  from  that  of  other  diphtheritic 
inflammations.  But  the  possibility,  and  perhaps  probability,  in  some 
instances  of  an  auto-infection  we  will  not  deny. 

Anatomical  Characters. — It  is  important  to  acquaint  ourselves 
with  the  anatomical  characters  of  croup,  especially  with  the  nature  of 
the  pseudo-membrane,  that  Ave  may  know  Avhat  measures  to  employ  in 
order  to  remove  it  and  prevent,  as  far  as  possible,  the  laryngeal  stenosis 
from  Avhich  so  many  perish.  The  surface  of  the  larynx,  trachea,  and, 
in  severe  cases,  that  of  the  bronchial  tubes,  is  hypersemic  and  SAvollen, 
and  the  inflammatory  action  involves  more  or  less  the  submucous  con- 
nective tissue,  causing  infiltration  or  oedema.  The  relation  of  the  exu- 
dation to  the  mucous  surface  varies  according  to  the  kind  of  epithelium 
present.  Where  the  epithelium  is  of  the  flat  or  squamous  variety,  the 
fibrinous  exudation  from  the  bloodvessels  is  poured  out  around  the  epi- 
thelial cells,  Avhich  perish.  If  the  inflammation  extend  more  deeply, 
the  underlvinf'  connective  tissue  is  also  embraced  in  the  coagulation  and 
perishes.  Prof.  Ziegler,  of  Tiibingen,  Avho  has  made  repeated  micro- 
scopic examinations  of  the  pseudo-membrane,  says :  "  It  sometimes 
happens  that  tlie  dead  epithelial  cells  become  saturated  Avith  the  exuded 
li(juid  and  then  pass  into  a  peculiar  condition  of  rigidity  akin  to  coagu- 
lation. The  seat  of  this  change  appears  to  the  naked  eye  as  a  dull, 
raised,  grayish  patch  surrounded  by  red  and  swollen  mucous  membrane. 
The  exudation  is  rich  in  albumen  and  tlie  transformed  cells  take  on  the 
appearance  of  a  kind  of  coarse  meshwork,  almost  or  altogether  devoid 
of  nuclei."  This  is  superficial  diphtheritis,  and  Prof.  Ziegler  next 
describes  deep  or  parenchymatous  diphtheritis  as  follows:  "It  is  char- 
acterized by  the  coagulation,  not  merely  of  the  epithelium,  but  also  of 
the  underlying  connective  tissue.  The  affected  patch  is  swollen  and 
assumes  a  Avhitish  or  grayish  tint,  the  discoloration  extending  through 
the  epithelium  to  the  connective  tissue  structures.  The  epithelium  in 
some  cases  is  lost  altogether,  and  then  the  diphtheritic  patch  consists  of 
dead  connective  tissue  only.  .  .  .  The  dead  ti.ssue  is  separated 
from  the  living  by  a  zone  of  cellular  inflammation.  Fibrinous  filaments 
are  seen  here  and  there  through  the  ma.ss.  The  lymj)hiitics  in  the 
neighborhood  contain  coagula  and  leucocytes." 

Squamous  epithelium  covers  the  nostrils,  buccal  cavity,  fauces,  the 


572  MEMBRANOUS   CROUP. 

larvnx  upon  and  above  tlie  superior  vocal  cord,  -with  the  exception  of  its 
anterior  aspect.  The  pseudo-membrane,  therefore,  upon  all  these  sur- 
faces lined  with  this  form  of  epithelium  consists  of  the  exudate  from  the 
blood  which  surrounds  and  permeates  the  epithelium,  or  epithelium  and 
subjacent  connective  tissue.  These  two  distinct  elements,  that  poured 
out  from  the  bloodvessels  and  the  normal  tissue  of  the  mucous  surface 
now  dead,  incorporated  in  one  mass,  therefore,  constitute  the  pseudo- 
membrane.  Its  intimate  relation  with  the  surrounding  livins;  tissue  is 
such  that  we  cannot  detach  it  without  lacerating  the  latter  and  causing 
bleeding. 

The  anterior  aspect  of  the  larynx  from  the  middle  of  the  epiglottis 
downward,  all  that  part  of  the  larvnx  below  the  superior  vocal  cord, 
the  entire  trachea,  and  the  bronchial  tubes,  are  lined  by  columnar  epi- 
thelium. Whenever  this  variety  of  epithelium  is  present,  the  exudate 
from  the  blood  does  not  become  incorporated  with  the  mucous  mem- 
brane, but  escapes  to  the  surface  and  coagulates  in  a  layer  over  it.  It 
is,  therefore,  loosely  adherent  to  the  underlying  tissues,  being  attached 
to  it  by  some  fibrinous  threads,  and  when  it  is  peeled  off,  the  hypergemic 
and  swollen  mucous  membrane  is  seen  underneath  in  its  entirety,  unless, 
as  is  commonly  the  case,  a  considerable  part  of  its  epithelium  has  been 
shed  and  been  expectorated.  The  loose  attachment  of  the  pseudo-mem- 
brane in  the  trachea  and  bronchial  tubes  is  of  the  greatest  significance 
in  its  relation  to  tracheotomy. 

In  this  connection  it  is  proper  to  call  attention  to  the  confusion  which 
occurs  in  the  use  of  the  terms  diphtheritic  and  croupous,  as  employed  by 
pathologists  on  the  one  hand,  and  clinical  observers  or  practitioners  on 
the  other.  Pathologists,  following  Virchow,  designate  the  inflammation 
diphtheritic  when  the  epithelium  and  underlying  tissues  remaining  in 
situ  are  blended  with  the  exudate  and  become  a  part  of  the  pseudo- 
membrane,  whatever  may  be  the  cause  of  the  inflammation,  and  they 
designate  the  inflammation  croupous,  whatever  its  cause,  when  the  exu- 
date escapes  to  the  surface  of  the  mucous  membrane,  as  in  the  trachea 
and  bronchial  tubes,  and  coagulates  upon  it.  Therefore,  in  all  cases  of 
pseudo-membranous  inflammation  of  the  air-passages,  even  that  due  to 
"taking  cold,"  or  to  inhalation  of  an  irritating  vapor,  they  term  the 
laryngitis  diphtheritic,  since  in  the  larynx  the  exudate  is  incorporated 
Avith  the  mucous  membrane,  while  the  pseudo-membranous  tracheitis  or 
bronchitis  in  the  same  patient  is  termed  croupous,  since  the  exudate  lies 
upon  the  surface.  Practitioners,  on  the  other  liand,  apply  the  term 
diphtheritic  to  all  inflammations  which  occur  as  local  manifestations  of 
the  specific  disease,  diphtheria,  and  only  to  such  inflammations,  Avhat- 
ever  may  be  their  form,  whether  pseudo-membranous  or  catiiiTJial. 

The  epithelial  cells  embraced  in  the  psendo-membrane  undergo  a  his- 
tological change.  We  have  stated  Ziegler's  remark  that  they  are  per- 
meated by  the  exudate  of  the  blood.  Cornil  and  Ranvier  say,  "  Wagner 
admits  the  fibrinous  degeneration  of  the  cells.  .  .  .  We  have  veri- 
fied the  description  given  by  Wagner,  but  we  would  conclude  that  the 
cells  are  filled  with  a  material  which  approaches  mucin  rather  than 
fibrin."  In  the  first  week,  the  ])seudo-membrane  forms  more  rapidly, 
and  is  usually  thicker  and  more  extended,  })roducing  dyspnoea  more 


SYMPTOMS.  Oio 

quickly  than  when  it  forms  in  the  declining  stage  of  the  disease.  If 
the  membrane  be  detached  by  the  forcible  coughing  of  the  patient,  it  is 
usually  quickly  reproduced  unless  the  diphtheria  be  in  its  advanced 
stawe  and  abating.  If  the  croup  continue  from  four  to  six  days,  the 
pseudo-membrane  begins  to  soften  from  commencing  decomposition  and 
to  disintegrate.  The  minute  fibres  which  attach  it  to  the  membrane 
give  way,  and  in  favorable  cases  by  the  effort  of  coughing  or  vomiting 
it  is  thrown  off.  Separation  is  aided  by  the  muco-pus  which  collects 
underneath. 

Symptoms. — Whenever  croup  is  one  of  the  local  manifestations  of 
diphtheria,  such  general  or  constitutional  symptoms  are  present  as  per- 
tain to  this  blood  disease,  such  as  febrile  movement,  anorexia,  thirst, 
and  progressive  loss  of  flesh  and  strength.  The  temperature  in  the 
commencement  in  croup  from  this  cause  is  usually  higher  than  at  an 
advanced  period,  unless  some  complication  occur,  as  pneumonia,  which 
increases  the  heat  of  the  system.  The  temperature  is  not,  however,  in 
the  beginning,  ordinarily  above  103°  or  104°,  and,  as  the  croup  con- 
tinues, and  the  systemic  blood-poisoning  becomes  more  marked,  the 
temperature  usually  falls,  so  that,  even  in  the  gravest  cases,  it  is  often 
at  or  below  100°.  Most  patients  also  have  those  inflammations  which 
commonly  attend  diphtheria,  i.  e.,  pharyngitis  and  more  or  less  coryza, 
but  they  are  relatively  unimportant  in  comparison  with  the  croup,  for, 
unlike  the  croup,  they  do  not  in  themselves  involve  immediate  danger  to 
life. 

Croup  commonly  begins  gradually  and  insidiously,  revealed  at  first 
to  the  physician  by  hoarseness  or  huskiness  of  the  voice,  and  a  hoarse 
or  harsh  cough.  Both  voice  and  cough  are  feeble,  lacking  the  fulness 
and  sonorousness  present  in  spasmodic  laryngitis.  In  grave  cases 
approaching  a  fatal  termination,  the  voice  becomes  more  and  more 
indistinct,  and  finally  is  suppressed.  The  cough,  also,  Avhich  in  the 
beginning  of  the  croup  was  strong  and  expulsive,  becomes  feeble  and 
ineffectual,  and  less  frequent  as  the  fatal  result  draws  near. 

The  amount  of  sputum  varies  considerably  in  different  cases.  If  the 
inflammation  extend  no  further  downward  than  the  trachea,  it  is  scanty, 
but  if  there  be  coexisting  bronchitis,  it  is  more  abundant,  consisting  of 
muco-pus  with  occasional  flakes  of  pseudo-membrane.  By  vomiting  a 
larger  quantity  is  expelled  than  by  the  cough.  Occasionally  masses  of 
psea<io-mcmbrane  of  considerable  size  are  expectorated,  even  moulds  of 
some  part  of  the  respiratory  passage,  always  Avith  great  temporary  relief 
to  the  patient.  A  pseudo-membrane  of  considerable  thickness  and  extent 
obstructs  the  expectoration  of  muco-pus,  which  collecting  in  the  lower 
part  of  the  trachea  and  in  the  bronchial  tubes,  greatly  increases  the  dys- 
pnoea. The  respiration  is  somewhat  more  frequent  than  in  health,  but 
it  is  not  notably  increased  except  when  bronchitis  or  broncho-pneumonia 
is  present.  At  an  advanced  stage,  when  stupor  supervenes  from  non- 
oxygenation  of  the  blood,  the  respiration  may  be  slower  than  in  health. 

Croup  in  its  commencement  and  in  the  active  period  of  dii)htheria 
without  treatment  almost  never  remains  stationary  or  abates.  Little  by 
little  or  often  quite  rapidly,  the  laryngeal  stenosis  increases,  and  soon 
the  patient  begins  to  experience  the  want  of  air.     He  becomes  restless. 


574  MEMBRANOUS   CROUP. 

has  an  anxious  expression  of  tlic  face,  seeks  change  of  position,  reaching 
out  his  arms  to  the  nurse  or  mother  to  obtain  relief.  In  some  patients 
only  a  few  hours  ehipse  and  in  others  a  day  or  more  of  gradual  increase 
in  the  obstruction,  when  it  becomes  evident  that  death  must  soon  occur 
unless  relief  be  afforded.  In  tliis  stage  tiie  post-clavicular,  infraclavi- 
cular, suprasternal,  and  inframanunary  regions  are  depressed  during  in- 
spiration, and  the  larynx  is  drawn  with  each  inspiratory  act  toward  the 
sternum.  While  there  is  constant  suffering,  there  are  also  occasionally 
most  distressing  attacks  of  dyspnoea  attended  by  an  increase  in  the 
lividity  of  the  features  and  extremities,  which  now  have  an  habitual 
dusky  pallor.  Sometimes  these  attacks  are  perhaps  due  to  the  doubling 
of  a  detached  end  of  the  pseudo-monibrane  on  itself,  or  perhaps  to  a 
movement  of  the  muco-pus  by  which  bronchial  tubes  are  occluded. 
With  the  ear  applied  over  the  larynx  or  upj)er  part  of  the  sternum,  a 
loud  rhonchus  is  heard  both  on  inspiration  and  expii-ation,  produced  by 
the  passage  of  the  air  over  the  obstruction,  and  obscuring  to  a  great 
extent  the  other  sounds.     Moist  bronchial  rales  are  also  common. 

Those  who  recover  from  membranous  croup  without  tracheotomy, 
and  by  the  use  of  inhalations,  and  thus  far  they  constitute  only  a  small 
minority,  usually  improve  gradually,  the  obstruction  diminishing  by 
softening  and  detaching  of  portions  of  the  pseudo-membrane,  the  cough 
becoming  looser  and  the  voice  less  hoarse.  After  the  detachment  of 
the  pseudo-membrane,  several  days  elapse  before  the  thickening  and 
infiltration  of  the  mucous  membrane  disappear  and  the  epithelial  cells 
are  restored. 

Diagnosis. — Catarrhal  laryngitis  with  an  unusual  amount  of  thick- 
ening and  infilti'ation  of  the  mucous  membrane  and  the  underlying  con- 
nective tissue,  so  as  to  produce  stenosis  and  obstruct  respiration,  may 
be  mistaken  for  pseudo-membranous  laryngitis.  In  the  New  York 
Foundling  Asylum,  two  children  have  at  different  times  died  with  the 
svmptoms  of  membranous  laryngitis,  and  the  obstruction  was  found  to 
be  due  entirely  to  the  thickening  and  infiltration  of  the  mucous  and  sub- 
mucous tissues  of  the  larynx  by  newly  formed  corpuscular  elements.  Of 
course,  death  from  catarrhal  laryngitis  is  rare,  but  that  this  disease  may 
produce  such  an  amount  of  laryngeal  stenosis  as  to  cause  even  fotal  dys- 
pnoea, like  that  from  the  presence  of  pseudo-membrane,  those  two  cases 
show.  In  most  instances,  the  diagnosis  of  membranous  laryngitis  from 
catarrhal  laryngitis  is  easy,  by  the  presence  of  patches  of  pseudo-mem- 
brane on  the  fauces,  or  by  the  history  of  the  case,  which  evidently  points 
to  diphtheria  as  the  cause.  I  have  elsewhere  alluded  to  a  child  in  my 
practice  who  died  with  the  symptoms  of  acute  laryngeal  stenosis,  with- 
out any  pseudo-membrane  upon  visible  parts,  and  with  only  a  moderate 
pharyngitis.  This  case,  which  might  have  passed  as  one  of  catarrhal 
laryngitis,  accompanied  by  an  unusual  amount  of  cellular  and  serous 
infiltration,  as  there  was  no  known  diphtheria  in  the  vicinity,  was  really 
due  to  diphtheria,  and  was  a  local  manifestation  of  that  disease,  for 
immediately  after  the  death  of  the  patient  the  two  nurses  had  unequiv- 
ocal symptoms  of  diphtheria.  The  difficulty  in  using  the  laryngoscope 
in  young  children  is  such,  when  their  fauces  are  swollen,  that  it  has  not 
heretofore  aided  much  in  the  differential  diagnosis  of  the  various  forms 


PROGNOSIS.  575 

of  acute  laryngeal  stenosis  in  young  children,  at  least  when  employed 
by  the  general  practitioner. 

Prognosis. — The  mortality  from  croup  obviously  depends  to  a  great 
extent  on  the  prevalence  and  the  type  of  diphtheria.  From  Avliat  has 
been  stated  above,  it  follows  that  croup  is  more  frequent  and  more  fatal 
in  a  grave  form  of  diphtheria  than  in  mild  epidemics  with  a  less  degree 
of  blood-poisoning.  In  New  York  City,  during  the  fifteen  years  ending 
with  1878,  the  percentage  of  recoveries  was  very  small,  both  under 
medicinal  treatment  and  tracheotomy.  During  this  long  period,  sur- 
gc'ons,  not  saving  more  than  three  to  five  per  cent,  of  their  cases  by 
tracheotomy,  performed  this  operation  reluctantly.  But  since  1878 
the  percentage  of  recoveries  after  tracheotomy  has  been  much  greater. 
The  mortality  from  croup  is  greater  the  younger  the  patient ;  for  the 
younger  the  child,  the  less  the  diameter  of  the  air-passages,  and  the 
more  quickly  laryngeal  stenosis  results.  The  younger  the  child,  also, 
the  more  difficult  is  the  use  of  the  proper  remedies,  and  the  less  the 
time  for  their  use  before  fatal  dyspnoea  occurs.  We  have  already  said 
that  croup  appearing  in  the  declining  stage  of  diphtheria  is  less  severe 
and  more  easily  controlled  or  cured  than  when  it  occurs  in  the  com- 
mencement of  diphtheria.  Much  depends,  also,  upon  whether  the 
physician  is  summoned  at  the  very  beginning  of  the  croup,  and  appro- 
priate remedies  are  early  and  persistently  employed.  In  many  in- 
stances the  friends  do  not  take  alarm,  and  the  physician  is  not  sum- 
moned till  the  disease  is  well  under  headway,  and  there  is  not  the  requi- 
site time  for  the  action  of  inhalations.  Obviously,  also,  croup,  beyond 
all  other  diseases,  requires  faithful  and  intelligent  nurses,  for  without  the 
coijperation  of  such  nurses  night  and  day,  in  the  care  of  the  ])atient,  the 
most  judicious  measures  are  often  rendered  inefficient. 

Exact  statistics  are  lacking  to  show  what  proportion  of  cases  of  croup 
recover  by  strictly  medicinal  treatment.  If  we  regard  as  incipient 
croup  those  cases  in  Avhich  the  voice  becomes  hoarse  or  harsh,  but  no 
dysj)noea  occurs,  and  the  lungs  are  fully  and  normally  inflamed,  a  con- 
siderable number,  I  think,  more  than  fifty  per  cent,  in  my  jtractice, 
recover.  There  may  be  in  these  cases  a  catarrhal  laryngitis,  or  there 
may  be  a  thin  film  of  pseudo-membrane  upon  the  laryngeal  surface,  not 
sufficient  to  embarrass  respiration.  Slight  laryngitis,  therefore,  occur- 
ring in  the  course  of  diphtheria,  unaccompanied  by  any  increase  in  tem- 
perature, or  change  in  the  freedom  or  rhythm  of  respiration,  and  whose 
only  symptom  is  a  huskiness  of  voice,  if  treated  early  and  properly  by 
inlialations,  passes  off  in  a  few  days  in  a  large  proportion  of  cases.  It 
possesses  little  importance  except  that  it  might  be  the  initial  stage  of 
croup  if  neglected.  It  is  obviously  improper  to  consider  this  trivial 
form  of  laryngitis  as  membranous  croup,  although  by  neglect  it  might 
become  such.  In  tlie  statistics  of  croup,  those  cases  only  sliould  be 
included  in  which  the  symptoms  are  so  pronounced  that  it  is  evident 
that  more  or  less  laryngeal  stenosis  is  present,  although  there  may  as 
yet  be  no  marked  dyspnoea. 

In  determining  the  percentage  of  recoveries  in  croup,  it  is  proper  to 
arrange  cases  in  two  groups:  1st,  cases  which  have  received  oidy  medi- 
cinal treatment;   2d,  cases  in  which  tracheotomy  has  been  ])erformeil. 


576  MEMBKANOUS    CKOUP. 

Having  been  in  almost  continuous  practice  since  diplitlieria  be^ian  in 
New  York,  in  a  section  of  the  city  •where  this  disease  has  always  been 
prevalent,  and  having  witnessed  all  kinds  of  treatment — that  by  emetics, 
by  depletion,  by  stimulation,  by  inhalation  and  insufflation — it  is  my 
opinion  that  not  more  than  one  in  eight  has  recovered  by  medicinal 
treatment  in  this  long  period,  of  cases  of  croup  which  began  in  the  lirst 
week  of  diphtheria,  and  in  which  the  symptoms  were  so  pronounced  as 
to  indicate  more  or  less  laryngeal  stenosis.  The  exudation  in  the  first 
week  of  diphtheria,  or  in  its  active  period,  occurs  so  rapidly,  and  in  such 
large  quantity,  that  no  one  of  the  medicinal  agents  or  modes  of  treat- 
ment, which  physicians  commonly  prescribe,  is  sufficiently  prompt  in  its 
action  to  prevent  the  formation  of  the  pseudo-membrane  to  an  extent 
that  soon  endangers  life.     I  allude  to  what  has  hitherto  been  the  result. 

Perhaps  we  may  yet  discover  a  mode  of  treatment  that  more  effectu- 
ally controls  the  formation  of  pseudo-membranes. 

Croup  occurring  in  the  second  or  third  week  of  diphtheria,  since  it  is 
attended  by  less  abundant  and  less  rapid  exudation  than  when  it  occurs 
during  the  acute  stage,  can  be  more  successfully  treated  under  the  per- 
severing use  of  solvent  inhalations,  and,  according  to  mv  observations,  a 
larger  proportion  than  one  in  eight,  perhaps  one  in  three,  recovers  by 
the  early  and  continuous  or  almost  continuous  use  of  inhalations. 

Still  the  mortality  is  so  large,  and  the  suffering  so  great  in  croup,  at 
whatever  stage  of  diphtheria  it  occurs,  that  we  cannot  rely  on  the  slow 
action  of  medicines  or  inhalations,  and  surgical  treatment  is  in  most  in- 
stances required  to  diminish  the  suffering,  and  afford  the  best  chances  for 
savino-  life.  Tubing  the  larynx,  to  which  we  will  allude  hereafter,  has 
been  so  seldom  performed,  and  the  statistics  of  it  are  so  meagre,  that 
we  are  unable  to  state  what  proportion  of  patients  may  be  saved  by  it. 
I  have  twice  observed  in  the  New  York  Foundling  Asylum  prompt  relief 
from  tubage,  when  the  dyspnoea  Avas  so  great  as  to  threaten  immediate 
death.  In  one  of  the  two  patients  the  relief  was  temporary,  and  in  the 
other  ])eruianent.  If  the  obstruction  were  confined  to  the  larynx  or 
larynx  and  ui)per  part  of  the  trachea,  tubage  would,  I  think,  come  into 
general  use  as  a  substitute  for  tracheotomy,  but,  unfortunately,  it  fails 
to  give  relief  and  save  life  in  those  many  cases  in  which  the  obstruction 
extends  throughout  the  trachea  and  into  the  bronchi.  The  statistics  of 
tracheotomy,  on  the  other  hand,  are  abundant,  and  we  are  enabled 
therefore  to  determine  to  what  extent  it  can  rescue  the  victims  of  thi? 
disease  from  impending  death.  The  American  Journal  of  Obstetrics 
for  May,  1868,  gives  the  results  of  tracheotomy  performed  by  Drs. 
Jacobi,  Krackowizer,  and  Voss  as  follows: 


Jacobi,  Kiackowizer,  and  Voss 

J.  II.  Ripley,  N.  Y.  Mod.  Ilpcord,  1880  . 

rarisian  Children's  Host).,  1851-187')  (Tcnnd) 

Bcthanien  in  Berlin,  1861-1872  (  Bartds) 

Berliner  Chirurg.  Klinilc,  1870-187G  (Kronlein)    504 

St.  Annen'ipital  Wien  (Monti)  . 

Table  (if  Monti  from  various  sources 

Hofmohl's  statistics 


Cases. 

Recove- 

Deaths. 

Per  cent,  of 

ries. 

recoveries. 

160 

30 

127 

— 

56 

16 

— 

— 

4663 





24 

380 

103 

— 

31.2 

504 

147 

— 

29 

210 

— 

— 

33 

2608 

— 

— 

25 

3760 

— 

— 

27 

PROGNOSIS, 


0/7 


Cases. 

Kiister's  Statistics         ......   looG 

C.  Hospital,  Trousseau,  Paris,  during  1883  (per 

Dr.  L.  Enfance) .3-39 

Clinic  of  the  Zurich  Kantonspitals,  under  Rose 
and  F.  Kronlein,  1868,  .March,  1882  (11  under 

2  ve.-irs,  1  of  8  months) 238 

Deutsche   Zeitschrift   fur   Chirurg.,    1882,    Bd. 

xvii.  (H.  Lindner) 101 

Statistik  der  Tracheotomie  per  Croup,  Deutsche 
Chirurger  Lieferung,  37  Stuttgurd,  1880,  by 
Kiihn      ........     277 

Hopital  des  Enfants  Malad.,  Paris,  1850-1857  .     389 
Hopital  des  Enfants  Malad.,  Paris,  18G0-1867  .     813 
Trousseau,  according  to  Kiihn   ....     46G 

Guersant  (Sedillot),  Med.  Oper.,  ii   page  480     .     171 
Barthef,  Hospital  St.  Eugenie,  1855-18G8  .     573 

Cases  in  the  Parisian  Hospitals  and  in  the  Pro- 
vinces, Fascher  et  Bricheteau         .         .         ,   1011 
Roser(Lissard),  C.  C,  1854-1861      ...       42 


rhde,  Archiv  f.  Klin.  Chir.  1869,  1820-1869      . 
Max  Muller  (Langenb.  Arch.  f.  Klin.  Chir.  vii.) 
Bardenheuer  (Coiner  Biirgerhospitals,  1875-1876) 
Krankenhause  Bethanien,  1873,  and  following  (H 

Settegast) 

Billroth,  Chirurg.  Klinik  AVien.,  1871-1876 

lleisz,  Bronchott  miens  Indicat.,  1858 

Wansher  (Copenhagener  Kommuni  Hospitals,  Sept. 

1863,  Dec.  187G) 


Recove- 
ries. 


115 


244 


Percent,  of 
recoveries. 

32 
32 


92 


125 
86 

208 

126 
36 

160 


19 


—  39 

—  37§ 

152     _ 


21 

28 

25 
45.4 


Operations.    Recove-    Per  cent,  of 
ries.         recoveries. 


81 
45 

129 


18 
■17 


400 


21 
15 

4G 

119 
1 


170 


25 
33 
35.6 

31.75 


42.5 


The  result  of  tracheotomy  in  inflmts  is  much  less  favorable  than  in 
older  children.  Dr.  Gustav  Chagin^  has  published  the  statistics  of 
cases  in  infancy.  These  cases,  977,  occurred  since  1874;  and  of  this 
number,  832,  or  85  per  cent.,  died.  In  the  Copenhagener  Kommuni 
Hospital,  in  which,  as  stated  above,  there  Avas  the  remarkably  good 
general  result  of  170  recoveries  in  400  tracheotomies,  only  5  per  cent, 
recovered  of  children  under  one  year;  of  76  operated  on  between  the 
ages  of  one  and  two  years,  22  recovered,  or  29  per  cent.;  while  of  296 
operated  on  between  the  ages  of  two  and  ten  years,  146  recovered,  or 
49.3  per  cent.  In  the  Krankenhause  Bethanien,  the  results  of  trache- 
otomy from  the  beginning  of  1861  to  the  close  of  1876,  tabulated  ac- 
cording to  the  age,  were  as  follows  (11.  Settegast): 

Age. 

2  to  3  years   . 

3  "  4     •' 

4  "  5     " 

5  "  6     " 

6  "  7     " 

7  "  8     " 

8  "  9     " 

9  "10     " 

The  Statistics  show  that  the  older  the  patient  upon  whom  tracheotomy 
is  performed,  other  things  being  equal,  the  greater  the  percentage  of 


Tracheotomies 

Recovered. 

Per  cent 

.       93 

22 

23.65 

.     1G5 

47 

28.45 

.     175 

54 

30  85 

.     107 

39 

35.45 

.       90 

34 

37.77 

.       59 

17 

38.86 

.       24 

11 

45.83 

.       15 

G 

40.00 

'  Archiv  fiir  Kindcrheilkundi 
37 


I5d.  iv, 


578  MEMBRANOUS   CROUP. 

recoveries.  Prof.  Abraliam  Jacobi  lias  probably  performed  tracheotomy 
for  croup  in  as  many  cases  as  any  other  ])hysician  or  surgeon  in  this 
country,  not  fewer,  he  thinks,  than  400  times.  His  opinion  corresponds 
with  the  common  belief  that,  during  the  last  five  years,  the  percentage 
of  recoveries  after  tracheotomy,  in  New  York  City,  has  been  much 
larger  than  previously,  and  the  operation  is  performed  more  frequently 
by  the  attending  pbysician  than  formerly.  The  result  of  tracheotomy 
during  a  long  series  of  years,  ending  with  1878  or  1870,  was  so  unfav- 
orable, on  account  of  the  type  of  tlie  disease,  that  Dr.  Jacobi  thinks,  in 
the  aggregate  of  his  cases  of  tracheotomy  since  1858,  only  about  12  per 
cent,  recovered. 

Although  at  present  in  this  city  the  percentage  of  recoveries  after 
tracheotomy  is  much  larger  than  formerly,  yet  the  statistics  of  some  of 
the  })rominent  physicians  and  surgeons  sliow  nearly  as  largo  a  propor- 
tion of  deaths  as  in  former  years,  probably  because  the  operation  has 
been  deferred  till  the  patients  were  nearly  moribund.  Thus,  one  sur- 
geon records  only  4  recoveries  in  21  operations  during  the  last  three  or 
four  years,  and  a  physician  of  large  experience,  connected  with  one  of 
the  institutions  where  children  are  treated,  has  been  equally  unsuccess- 
ful in  his  tracheotomies,  but  he  has  operated  only  when  the  dyspnoea 
Avas  extreme,  and  death  momentarily  expected.  Earlier  operation 
might  have  given  better  results. 

The  statistics  of  recent  tracheotomies,  which  seem  to  me  to  indicate 
most  accurately  the  results  of  this  operation  Avhen  skilfully  performed, 
and  not  at  too  late  a  stage  in  the  type  of  diphtheria  now  prevailing  in 
this  city,  I  have  oljtained  from  Drs.  J.  H.  Ripley  and  Fred.  Lange. 
The  operations  embraced  in  their  statistics  were  performed  since  Jan- 
uary 1,  1870,  with  the  f(jllowing  result: 

Tracheotomies.  Died.  Recovered.  Per  cent,  of  recoveries. 

6G  44  22  33J 

These  surgeons  do  not  select  cases  for  the  operation,  but  they  operate 
on  nearly  every  patient  with  croup,  to  whom  they  are  summoned,  pro- 
vided that  death  seems  inevitable  without  tracheotomy.  They  operate 
even  if  serious  complications  be  present,  as  nephritis  or  pneumonia,  or 
the  blood  be  profoundly  poisoned.  With  them  the  inducement  to 
operate  is  sufficient  if  tracheotomy  diminish  the  suffering,  or  increase 
the  chances  or  recovery  in  however  trifling  a  degree.  Inasmuch,  there- 
fore, as  they  do  not  select  cases,  so  good  a  result  is  noteworthy. 

Some  physicians  in  this  city  make  greater  discrimination  in  cases,  and 
do  not  operate  if  the  condition  of  the  patient  be  such  that  deatli  will  in 
all  probability  occur  after  tracheotomy.  They  do  not,  therefore,  advise 
the  operation,  if  the  patient  have  profound  blood-poisoning  or  severe  local 
disease  elsewhere  than  in  the  air-passages.  Such  physicians  by  the  early 
performance  of  tracheotomy,  and  by  careful  attention  to  the  after-treat- 
ment, making  frecpient  visits  and  supervising  the  details  of  the  manage- 
ment, furnisli  more  favorable  statistics  of  the  operation  than  those  pub- 
lished above.  Thus,  Dr.  A.  R.  Robinson,  who  carefully  considers  the 
indications  and  contraindications  of  tracheotomy,  who  operates  early, 


PREVEXTIYE    TREATMEXT.  579 

does  not  insert  tlie  canula  until  all  loose  muco-pus  and  shreds  of  pseudo- 
rnembrane  are  expelled  by  the  cough  from  the  trachea  and  bronchial  tubes, 
and  who  supervises  by  frequent  visits  the  after-manao:enient,  has  saved 
since  1880  eleven  in  thirteen  consecutive  cases  of  undoubted  membranous 
croup.  It  is  seen  from  the  above  statistics  that  "vve  can  claim  for  trache- 
otomy judiciously  performed,  and  at  a  sufficiently  early  stage,  the  cure 
of  one  in  every  three  patients  in  the  average.  The  statistics  in  Boston 
show  that  the  results  obtained  in  that  city  in  hospital  practice  have  been 
about  the  same  as  those  in  New  York  and  in  European  cities.  In  an 
interesting  paper  on  tracheotomy  in  croup,  published  in  the  Medical 
JVetvs,  July  12,  1884,  the  writer  says:  "Tracheotomy  for  this  disease 
has  been  performed  one  hundred  and  eighteen  times  at  the  Boston  City 
Hospital  during  the  past  twenty  years.  Thirty-nine,  or  one  in  three, 
were  successful.  That  the  cases  were  not  selected  is  shown  by  the  fact 
that  thi-ee  patients  died  during  the  operation  from  shock  and  exhaustion, 
not  from  hemorrhage;  thirty-four  died  within  twenty-four  hours;  and 
fifty-six,  or  more  than  one-half  of  the  fatal  cases,  within  forty-eight  hours. 
Four,  if  not  five,  of  the  successful  cases  were  practically  moribund  at 
the  time  of  the  operation.  .  .  .  The  ages  of  these  patients  ranged 
from  nine  months  to  forty-one  years.  The  youngest  to  recover  was 
eleven  months  ;  the  oldest  sixteen  years.  Four  aged  two  years  and  five 
aged  tlu'ee  years  got  well.  ^Membrane  was  visible  in  the  fauces  or 
trachea  in  a  large  proportion  of  both  the  successful  and  unsuccessful 
cases.  Its  absence  was  noted  in  only  three  of  each  class.  It  need  not 
be  said  that  in  every  instance  there  was  present  severe,  constant,  and  in- 
creasing dyspnoea,  exhausting  the  strength  and  threatening  suffocation." 

Preventive  Treatment. — In  attending  a  case  of  diphtheria  the 
physician  should  notice  at  each  visit  whether  the  patient  have  any 
hoarseness  or  other  signs  indicating  implication  of  the  larynx,  since,  if 
the  danger  be  recognized  at  its  inception,  it  may  perchance  be  averted. 
Ineffectual  as  inhalations  may  be  for  fully  declared  croup,  we  have  seen 
in  speaking  of  the  prognosis  that  experience  fully  justifies  the  belief 
tliat  they  are  sufficient  in  a  large  proportion  of  cases  to  relieve  that  de- 
gree of  laryngitis  which  is  indicated  by  simple  hoarseness,  and  which  if 
it  continue  miglit  eventuate  in  serious  obstructive  disease.  If  the  physi- 
cian observe  such  symptoms,  he  should  immediately  recommend  that  the 
air  in  the  apartment  be  kept  moist  by  the  croup  kettle  or  pans  of  hot 
water  over  tiie  fire,  into  each  of  which  a  lump  of  lime  is  placed.  I  fre- 
quently surround  the  bed  with  a  tent  made  with  a  clothes-horse,  over 
which  blankets  are  tlirown,  and  place  the  croup  kettle  underneath. 
Frequently  stirring  tlie  Avater  in  tlie  kettle  a<lds  to  its  efficiency.  I 
prefer,  however,  in  most  instances,  to  employ  the  steam  atomizer  either 
with  or  without  the  croup  kettle.  It  should  be  so  constructed  that  it 
throws  a  lieavy  spray  of  rather  turbid  lime-water,  and  should  be  ahnost 
continuously  used  as  long  as  the  premonitory  symptoms  of  croup  con- 
tinue. It  obviates  the  necessity  of  heating  the  apartment,  whicli  in  liot 
weather  is  very  uncomfortable. 

It  is  proper,  in  this  connection,  to  consider  which  is  the  most  efficient 
and  the  best  agent  for  inhalation  in  croup.  Have  we  an  agent  that  can 
be  safely  used,  which  will  prevent,  when  inhaled,  the  formation  of  the 


580  MEMBRAXOUS   CROUP 

pseudo-membrane,  or  which  will  dissolve  it  when  it  has  already  formed? 
The  agents  Avliieh  liave  been  most  employed  for  this  purpose  are  lime- 
water,  lactic  acid,  pepsin,  and  bromine. 

In  selecting  the  one  that  is  safest  and  most  efficient,  the  important 
fact  should  be  borne  in  mind  that  anything  which  irritates,  so  as  to  in- 
crease the  inflammation  of  the  mucous  surface,  is  injurious.  AYhatever 
intensifies  the  inflammation,  evidently  augments  the  thickening  and  in- 
filtration of  the  mucous  membrane,  and  increases  the  area  as  well  as 
thickness  of  the  pseudo-membrane.  It  is  therefore  harmful  instead  of 
1)eneficial.  In  my  opinion  the  teachings  of  Bretonneau  and  Trousseau 
did  immense  harm  in  the  fact  that  they  brought  into  use  agents  far  too 
irritating  to  the  sensitive  mucous  surface.  Since  the  pressing  danger 
in  crou})  arises  from  the  obstruction  ])roduced  by  the  pseudo-membrane, 
and  by  the  thickening  and  infiltration  of  the  mucous  membrane  under- 
neath, that  agent  is  indicated,  if  it  can  be  found,  which  loosens  and  dis- 
solves the  pseudo-membrane,  and  at  the  same  time  tends  to  diminish  or 
at  least  does  not  increase  the  inflammation  of  the  underlying  tissues  by 
its  irritatincr  action.  Alkalies  exert  a  solvent  action  on  fibrin  and  mucin, 
and  as  the  pseudo-membrane  consists  of  the  exudate  from  the  blood 
largely  fibrinous,  and  of  epithelium  and  connective  tissue  which  have 
undergone  degeneration  into  a  substance  resembling  fibrin  (Wagner)  or 
perhaps  mucin  (Cornil  and  Ranvier),  their  employment  seems  to  rest  on 
a  sound  therapeutic  basis.  Lime-water  slightly  turbid,  but  not  so  turbid 
as  to  clog  the  point  of  the  steam  atomizer,  and  containing  about  one 
and  a  half  per  cent,  of  liqour  potassiie,  is  probably  as  efficient  and  useful 
a  solvent  as  any  of  the  alkaline  mixtures  which  have  been  commonly 
used.  One  and  a  half  per  cent,  liquor  potassfB  becomes  about  one  per 
cent,  when  mixed  Avitli  steam  from  the  boiler.  Dr.  E.  M.  Moore, ^  of 
Rochester,  recommends  insuflSation  of  sodium  bicarbonate  as  an  active 
solvent  of  the  pseudo-membrane.  It  possesses  this  advantage,  that  it  is 
but  slightly  irritating,  so  that  it  can  be  used  in  substance  or  with  but 
little  dilution.  For  this  reason  it  should  be  preferred  to  lime-water, 
which  is  in  more  common  use. 

By  the  persistent  and  timely  use  of  such  inhalations  as  soon  as 
hoarseness  appears,  croup  can,  in  my  opinion,  be  often  prevented.  But 
we  all  know  how  often,  notwithstanding  our  best  endeavors,  croup  oc- 
currino-  in  the  first  week  of  diphthei-ia  grows  hourly  worse.  In  these 
acute  and  rapid  cases  inhalations  of  the  best  agents  which  physicians 
have  hitherto  used,  act  too  slowly  to  prevent  the  growth  of  the  pseudo- 
mcndjrane,  and  in  a  few  hours  it  becomes  painfully  evident  that  some- 
thing more  must  be  done  or  the  life  of  the  child  is  lost.  In  those  many 
cases  in  which  diphtheria  is  ushered  in  with  croupous  symptoms,  and 
in  which,  within  a  few  hours,  laryngeal  stenosis  begins  to  occur,  the 
experienced  physician  sees  at  a  glance,  often  at  his  first  visit,  that  inha- 
lations, however  fiiitlifidly  emplo^'cd,  will  be  inadequate,  and  that  suffo- 
cation, the  most  painful  of  all  modes  of  death,  will  be  inevitable,  unless 
other  and  energetic  measures  are  used. 

On  the  other  hand,  in  the  milder  forms  of  croup,  in  which  the  exuda- 

^  Transactions  of  the  N.  Y.  Medical  Association,  ISSo. 


PREVEXTIVE    TREATMEXT.  581 

tion  has  but  moderate  thickness  and  forms  slowly,  inhalations  are  of  the 
greatest  service,  and,  aided  by  internal  remedies,  they  not  infrequently 
arrest  the  disease  and  save  life.  The  following  was  such  a  case  :  M.  J., 
a  girl  of  two  years  and  five  months,  took  diphtheria  on  January  6, 1884. 
I  first  saw  her  on  the  9th,  when  a  considerable  amount  of  pseudo  mem- 
brane covered  the  fauces.  The  temperature  was  but  moderately  ele- 
vated, and  a  slight  discharge  occurred  from  the  nostrils.  Under  the 
usual  treatment  the  pharyngitis  abated,  and  she  seemed  to  be  convales- 
cing until  January  14th,  when  her  respiration  began  to  be  noisy  and 
embarrassed.  On  inspecting  the  fauces  a  pseudo-membrane  was  seen 
upon  the  aperture  of  the  glottis,  apparently  dipping  down  into  it.  The 
steam  atomizer  was  employed  almost  constantly,  throwing  a  spray  of 
lime-water  with  about  one  per  cent,  of  liquor  potassie.  Each  inspira- 
tion was  accompanied  by  marked  depression  of  the  post-clavicular,  epi- 
gastric, and  inframammary  regions,  and  the  respiration  was  noisy  and 
embarrassed  till  the  ITth,  when  it  began  to  improve,  and  the  patient 
was  soon  out  of  danger.  It  will  be  observed  that  the  croup  commenced 
in  the  second  week  or  in  the  declining  stage  of  diphtheria.  Had  it  been 
earlier,  when  the  inflammation  Avas  more  active,  and  the  exudation 
more  rapid,  in  all  probability  the  patient  would  have  perished  unless 
saved  by  tracheotomy.  The  slowness  of  the  exudative  process  afforded 
time  for  the  action  of  solvent  inhalations.  Nearly  at  the  same  time  that 
this  case  occurred,  a  patient  in  my  practice,  who  had  recovered  from  croup 
by  tracheotomy,  Avas  seized  with  dyspnoea  a  month  after  the  operation, 
Avhen  the  opening  had  healed,  and  a  flapping  sound  could  be  distinctly 
heard,  produced  probably  by  a  pseudo-membrane,  which  w^as  partially 
detached.  This  obstruction,  which  for  a  time  a))parently  involved 
great  danger  from  the  dysjmoea  which  it  caused,  Avas  removed  by  the 
third  day  under  alkaline  inhalations.  In  such  cases,  in  Avhich  the 
inflammation  is  mild  and  the  exudation  at  a  standstill,  or  slow,  the 
benefit  from  inhalations  is  most  apparent.  I  am  confident  that  one 
good  residt  from  alkaline  inhalations  is  not  fully  appreciated  by  the 
profession ;  I  refer  to  the  fact  that  they  render  the  muco-pus,  Avhich 
collects  in  large  quantity  in  the  bronchial  tubes,  and  is  expectorated 
Avith  difficulty,  on  account  of  its  viscidity,  and  the  obstacle  above  it, 
thinner  and  more  easily  expelled. 

NoAv  that  diphtheria  has  become  so  prevalent  in  this  country,  and  so 
many  children  perish  of  the  croup  Avhich  it  produces,  it  is  to  be  hoped 
that  some  more  efficient,  and  at  the  same  time  unirritating  substance 
may  be  discovered  for  inhalation  than  those  at  present  in  use. 

Since  my  attention  has  been  called  to  the  fact,  by  Dr.  Van  Syckcl, 
of  NcAV  York,  that  trypsine,  one  of  the  digestive  ferments  secreted  by 
the  pancreas,  is  a  rapid  solvent  of  fibi-in,  he  having  observed  its  action 
in  the  lal)oratory  of  J*rof  Kiiline,  of  Heidelberg,  I  have  employed  this 
agent  in  the  usual  form  of  diplitlicria  in  several  instances  Avith  such 
result  as  to  encourage  the  hope  that  the  solvent  Avhich  avc  have  so  long 
needed  has  been  found.  I  liave  never  seen  pseudo-membranes  disap- 
pear from  the  fauces  more  rapidly  than  in  cases  in  Avhich  the  folloAving 
mixture  was  applied,  every  half  hour,  Avith  a  large  camel's-hair  pencil, 


582  MEMBRANOUS   CROUP. 

■whether  the  good  effect  was  due  to  the  trypsine  contained  in  the  extract, 
or  to  the  alkah.  or  to  the  combination  of  the  two  : 

Extract!  pancreatis  (Fairchild's)  ....      ^^^j. 

Sodii  bicarbonat.  .......      giij- — Misce. 

Add  one  teaspoonful  of  this  to  six  teaspoonfuls  of  water. 

Thus  recently,  in  a  chihl  of  about  five  years,  a  thick  pseudo-mem- 
brane over  each  tonsil  had  disappeared  by  the  third  day,  without  appa- 
rently any  irritating  effect  from  the  application.  Mr.  Fairchild  has 
recently  prepared  trypsine  in  a  liquid  form,  in  order  that  its  efificacy  can 
be  more  readily  and  conveniently  tested  as  a  solvent  for  the  membranes 
in  croup :  and  Dr.  IL  D.  Cliapin  informs  me  that  this  liquid  emj)loyed 
in  sprav  quickly  dissolved  the  pseudo-membrane  in  situ  upon  the  larynx 
removed  from  an  infant  that  perished  from  this  disease.  Additional 
clinical  observations  will  soon  determine  the  value  of  trvpsine  as  a  sol- 
vent, and  whether,  if  it  be  a  good  solvent,  it  can  be  utilized  as  a  spray. 
That  it  requires  an  alkaline  medium  for  its  activity  renders  it  compat- 
ible Avith  alkaline  inhalations. 

Internal  Treatment — Calomel. — Tiiis  was  long  regarded  as  the 
most  important  internal  remedy  for  membranous  croup,  as  well  as  for 
diphtheritic  exudations  elsewhere  than  in  the  larynx.  In  the  belief 
that  it  had  a  tendency  to  prevent  the  formation  of  pseudo-membranes, 
and  aided  in  detaching  and  removing  those  already  formed,  it  was  in 
conniion  use  until  about  twenty-five  years  ago.  It  was  sometimes  pre- 
scribed for  croup  in  large  doses,  but  more  frequently  in  doses  of  one- 
half,  one,  or  one  and  a  half  grains,  repeated  every  second  or  third  hour, 
and  often  in  combination  with  an  opiate,  as  Dover's  powder.  However 
useful  a  remedy  it  may  be  when  judiciously  employed  in  croup,  as  well 
as  in  certain  other  diseases,  it  fell  into  disuse  on  account  of  its  ill-advised 
employment  in  diseases  which  did  not  require  it,  its  enqiloyment  often 
to  the  extent  of  producing  unpleasant  and  even  dangerous  symptoms. 
When  diphtheria  was  established  in  this  country,  calomel  Avas  in  a  few 
"vears  discarded  by  most  physicians  as  a  remedy  for  croup,  on  account 
of  the  growing  belief  that  nearly  all  cases  of  this  disease  were  local 
manifestations  of  diphtheria,  and  required  less  depressing  and  more 
sustaining  measui'cs  than  mercury.  Moreover,  it  was  easy  to  point 
out  cases  in  the  writings  of  such  masters  of  the  profession  as  Breton- 
neau  :ind  Trousseau,  in  which  calomel  Avas  improperly  employed,  doing 
harm  by  causing  not  only  severe  salivation,  but  also  gangrene.  Never- 
theless cases  occurrctl  in  those  days  which  seemed  to  show  that  this 
agent  properly  employed  is  a  potent  and  useful  remedy  for  croup.  One 
in  the  Astor  House  of  New  York  attracted  much  attention.  A  child  of 
about  tAvo  years,  stopping  at  this  hotel,  had  pseudo-membranous  laryngitis, 
Avith  constant  and  increasing  dyspnoea.  Prominent  physicians  summoned 
to  him  expressed  the  opinion  that  he  could  not  live,  Avhcn,  through  the 
advice  of  a  physician  from  an  inland  city,  Avho  Avas  temporarily  sojourn- 
ing in  the  hotel,  twenty  grains  of  calomel  Avere  placed  on  his  tongue. 
From  this  time  the  dyspnoea  began  to  abate,  and  the  patient  recovered. 
The  medical  journals  from  time  to  time  contain  reports  of  cases  of 
croup  in  Avhicli  calomel  has  apj)arently  been  beneficial.      Dr.  J.  P.  Klin- 


IXTERXAL  TREATMENT CALOMEL.  583 

gensmith,^  of  Blairsville,  Pennsylvania,  states  that  ])li_vsicians  in  his 
locality  prescribe  calomel  in  large  doses  for  croup,  and  with  greater  suc- 
cess than  that  achieved  by  other  modes  of  treatment,  and  he  relates 
three  cases,  showing  the  result  in  his  own  practice: 

Case. — A  child  aged  28  months  took  twenty  grains  of  calomel  placed 
on  the  tongue  in  the  commencement  of  croup,  and  afterwards  ten  grains 
every  hour  till  the  third  day  when  720  grains  had  been  taken.  It  was 
now  discontinued,  and  on  the  sixth  day  the  jiseudo-membrane  had  disap- 
I^eared.     Recovery  Avas  rapid,  and  without  any  untoward  symptoms. 

Case. — The  second  patient,  aged  three  and  a  half  years,  had  been  sick 
forty-eight  hours,  with  a  temperature  of  102°  F.  He  had  a  croupy  cough, 
and  a  pseudo-membranous  exudation.  Twenty  grains  of  calomel  were 
administered  and  afterwards  ten  grains  every  hour  for  fifteen  hours,  so 
that  one  hundi'ed  and  seventy  grains  were  administered.  The  child, 
which  had  previously  been  restless,  fell  into  quite  a  natural  sleep.  The 
calomel  was  discontinued,  and  a  mixture  of  potassium  chlorate  and  am- 
monium chloride  given  in  its  place.  On  the  fifth  day  convalescence  was 
fully  established,  without  any  unfavorable  symptoms. 

Case. — Tiie  third  patient,  a  girl  of  four  years,  had  been  sick  twenty- 
four  hours,  with  "  high  temperature,  painful  croupy  cough,  labored  respi- 
ration, dry  skin,  flushed  fa«e,  and  some  diphtheritic  "  exudation.  Twenty 
grains  of  calomel  were  administered  and  fc^lh^wed  by  hourly  ten  grain 
doses,  till  twelve  doses  were  given.  No  other  remedy  was  employed,  and 
in  three  or  four  days  the  patient  recovered. 

These  appear  to  have  Ijccn  genuine  cases,'  and  that  tliey  recovered 
tends  to  confirm  the  belief  that  calomel  does  exert  a  beneficial  action  on 
pseudo-membranous  inflammations,  either  diminishing  the  exudation,  or 
promoting  the  liquefaction  and  detachment  of  the  pseudo-membrane. 

A  mode  of  treatment  commonly  accepted  and  practised  by  the  profes- 
sion through  a  long  series  of  years  usually  does  some  good,  in  at  least  a 
certain  pro[K)rtion  of  cases,  even  if  it  be  abused,  else  it  would  not  have 
been  likely  to  gain  general  acceptance.  We  know  how  quickly  calomel 
cures  the  mucous  patches  of  syphilis,  even  when  they  are  of  large  size. 
These  are  produced  by  inflammatory  changes  in  the  tegumentary  system, 
and  they  consist  largely  of  epithelial  or  epidermic  cells.  They,  there- 
fore, contain  elements  similar  to  the  pseudo-mem1)rane  in  croup,  but 
without  the  fibrin.  We  know  also  how  readily  fibrinous  opacities  on 
the  cornea  yield  to  calouiel  dusted  on  them.  We  may  ailmit  that  calomel 
jtrobably  exerts  a  salutary  action  either  on  the  exudative  process  or  the 
pseudo-membrane,  without  being  able  to  state  precisely  how  it  acts. 
Bouchut  says  of  calomel  in  his  article  on  croup:  "This  medicine  pro- 
motes the  expectoration  and  the  rejection  of  the  false  membrane." 
Trousseau  believed  that  the  beneficial  etfects  of  the  mercurial  ])repara- 
tions  were  due  mainly  to  their  local  action.  lie  states  that  "wherever 
they  can  be  applied  locally"  they  "modify  most  powerfully  the  diph- 
theritic inflammation."  He  dusted  the  inflamed  surface,  if  accessible, 
with  calomel,  or  with  a  powder  of  the  red  ]ir('cipitate,  one  part  to  twelve 
of  pulverized  sugar.     The  use  of  tlie  mercurial  collar  for  the  neck  in 

»  Med.  Kecord,  July  12,  1884. 


o84  MEMBRANOUS   CROUP. 

the  treatment  of  croup,  employed  and  recommended  by  Bretonneau,  is 
familiar  to  those  Avho  have  read  his  memoirs.  Professor  Jacobi  also, 
"who  has  probably  given  more  attention  to  diphtheria  than  any  other 
physician  in  America,  apparently  believes  that  mercury  used  locally  is 
beneficial  in  croup,  for  he  has  recently  recommended  inunction  with  the 
oleate  of  mercury  upon  the  neck,  whenever  the  bicldoride  of  mercury 
administered  internally  disagrees.  It  has  seemed  to  me  that  one  or  tun 
large  doses  of  calomel  administei'ed  in  the  commencement  of  croup,  "vvhen 
there  is  no  decided  cachexia,  do  exert  a  beneficial  action  on  the  course 
of  the  disease,  as  in  the  folloAving : 

Case. — R.,  male,  aged  three  years,  began  to  be  croupy,  but  without 
any  marked  imi)airiiient  of  the  voice,  on  November  7,  1884.  The  mother 
states  that  he  has  had  sore  throat  nearly  one  week,  but  without  medical 
attendance.  He  began  to  be  croupy  on  November  7th,  and  his  r(>spira- 
tion  gradually  became  more  noisy  and  difficult  till  the  evening  of  the  8th, 
Avheu  I  was  asked  to  see  him. 

His  temperature  was  99^.  The  dyspnoea  was  such  that  the  post-clavi- 
cular, suprasternal,  and  infranuunmary  regions  were  depressed  on  inspi- 
ration, and  his  breathing  was  noisy,  but  the  voice  had  nearly  the  usual 
clearness.  The  fixuces,  though  red,  were  not  notably  swollen,  and  a  pseudo- 
membranous patch  of  the  size  of  the  nail  of  the  littlo  finger  lay  over  the 
right  tonsil.  The  diagnosis  was,  therefore  made  of  mild  diphtheria,  but 
with  dangerous  laryngeal  stenosis,  probably  from  the  presence  of  a  pseudo- 
membrane  ;  general  condition  of  the  child  good.  Six  grains  of  calomel 
were  placed  on  the  tongue,  and  inhalation  was  ordered  by  the  steam 
atomizer  of  the  following : 

R. — Liquor  potassas       .......     J^j. 

Aquffi  calcis    ........     Oj. — Misce. 

The  record  of  November  10  states:  Resp.  38  per  minute,  still  noisy 
but  no  increase  of  dysjmcea;  pulse  126;  temperature  in  groin  99,i°;  slight 
discharge  from  nostrils ;  uses  the  inhalation  almost  constantly.  P^'rom 
this  date  the  pseudo-membrane  and  redness  of  the  fauces  gradually  disap- 
peared, and  two  days  later  the  patient  was  out  of  danger. 

The  results  of  the  treatment  of  diphtheria  and  of  the  inflammations 
which  accompany  this  disease  are  liable  to  produce  an  erroneous  opinion 
in  regard  to  the  value  of  therapeutic  agents,  since  cases  diff"er  so  greatly 
in  type  or  severity.  But  the  experience  of  many  physicians  justifies 
^he  belief  that  mercury  and  especially  calomel,  employed  within  certain 
limits  in  the  commencement  of  a  pseudo-membranous  inflammation,  does 
exert  some  controlbng  action  on  this  disease.  That  it  did  much  harm 
formerly  when  physicians  prescribed  it  as  freely  as  we  now  employ 
potassium  chlorate  to  the  extent  in  many  instances  of  inci-easing  the 
cachexia,  and  causing  mercurialism,  should  not  deter  from  its  judicious 
use.  In  the  ordinary  form  of  diphtheria  I  would  not  advise  the  use  of 
calomel,  or  woidd  limit  its  employment  to  one  or  two  doses  of  six  to  ten 
grains  in  the  commencement  of  the  disease  in  robust  cases.  But  in 
croup,  since  the  danger  is  not  from  the  cachexia  or  blood-poisoning  so 
much  as  from  the  laryngeal  stenosis  which  usually  develops  rapidly, 
that  medicine  is  indicated,  and  should  be  prescribed,  which  most  strongly 


IXTERXAL    DISIXFECTAXTS    OR    GERMICIDES.  585 

retards  the  exudative  process,  and  aids  in  liquefying  and  removing  the 
pseudo-membrane ;  provided  that  it  produce  no  deleterious  ettcct  which 
renders  its  use  inadmissible.  Hence  it  is  proper  to  prescribe  calomel  in 
larger  doses  and  for  a  longer  time  in  the  treatment  of  croup,  than  in 
other  forms  of  membranous  inflammation,  if  it  fulfil  the  indication  as  it 
seems  to  in  a  measure.  In  my  own  practice,  hoAvever,  calomel  is  not 
prescribed  after  the  first  or  second  day,  since  I  prefer  the  use  of  other 
remedial  measures,  which  are  efficient,  and  are  less  likely  to  produce  in- 
jurious effects. 

Emetics. — These  have  been  largely  used  in  all  forms  of  croup,  and 
in  catarrhal  or  spasmodic  croup  they  usually  produce  marked  relief. 
Formerly  emetics  were  much  employed  in  the  treatment  of  membranous 
croup,  but  now  that  diphtheria  has  spread  throughout  the  country,  and 
most  cases  of  this  form  of  croup  occur  in  patients  suffering  from  diph- 
theritic blood-poisoning,  depressing  emetics  as  ipecacuanha  and  antimony 
have  fallen  into  disuse  since  they  were  found  to  be  badly  tolerated.  In 
my  practice  a  child  of  ten  years  with  severe  diphtheria  and  w'ith  com- 
mencing croupy  symptoms,  sank  rapidly  and  died  between  two  of  my 
visits,  from  exhaustion  produced  by  a  single  large  dose  of  ipecacuanha 
administered  by  anxious  parents  without  my  advice. 

]jut  an  emetic  gives  partial  relief  to  the  dyspnoea  in  certain  cases, 
since  it  assists  in  expelling  the  muco-pus  which  blocks  up  the  tubes 
below  the  pseudo-membranes,  and  sometimes  portions  of  pseudo-mem- 
brane which  are  easily  detached.  If  an  emetic  be  employed,  one  should 
be  selected  which  acts  promptly  with  little  depression,  and  as  a  rule  it 
should,  I  think,  only  be  used  at  the  commencement  of  croup.  If  after 
the  initial  period  there  bo  that  degree  of  dyspnoea  which  suggests  its 
use,  tracheotomy  is  preferable  as  more  likely  to  give  relief,  and  save  the 
patient.  Of  the  emetics  which  are  admissible  in  the  commencement  of 
croup,  sulphate  of  copper  is  one  of  the  best.  Several  years  since  in  one 
case,  in  which  there  were  at  my  first  visit  dyspnoea,  croupy  cough,  and 
a  pseudo-membrane  over  each  tonsil,  and  in  which  I  had  made  an  un- 
favoral)le  prognosis,  the  parents,  ol)serving  the  good  effects  of  two  grains 
of  sulphate  of  copper,  repeated  the  dose  every  two  to  four  hours  till  the 
following  day,  and  the  patient  recovered.  Such  a  result  however  I 
regard  as  exceptional.  Probably  in  ordinary  cases  the  best  emetic  is 
the  yellow  sulj>hate  of  mercury  or  turpeth  mineral  in  a  powder  of  two 
or  three  grains.  The  use  of  this  euietic  in  croup  Avas  prominently 
brought  to  the  notice  of  the  profession  by  Prof.  Fordyce  Barker,  who 
administered  this  agent  immediately  after  being  summoned  to  a  case, 
and  he  alleges  with  remarkable  benefit  to  his  patients.  It  has,  however, 
been  recently  stated  on  apjjarcntly  good  authority  that  turpeth  mineral 
when  it  enters  the  stomach,  although  it  causes  vomiting,  is  not  itself 
ejected  unk'ss  in  small  quantity,  so  that  a  considerable  share  of  its  action 
may  be  through  its  absorption  and  like  that  of  calomel. 

Internal  DisiNrccTANTS  ou  Germicides. — The  theory  which 
happens  to  prevail  regarding  the  nature  of  a  disease  necessarily  inHu- 
ences  the  treatment.  It  is  now  commonly  believed  that  di|)htheria  is 
produced  by  bacteria,  and  therefore  the  use  of  agents  which  are  de- 
atructivc  to  microorganisms  is  at  once  suggested  as  the  proper  treat- 


586  MEMBRANOUS   CROUP. 

ment  for  diphtheria,  and  for  the  inflammations  which  the  specific  prin- 
ciple of  diphtheria  gives  rise  to.  Hence  sulphite  of  sodium,  sulpho- 
carbolate  of  sodium,  the  phenic  acid  of  Declat,  and  chlorine  preparations 
have  been  administered  internally  in  the  treatment  of  dii)htheria,  but 
whether  they  produce  a  better  result  than  iron  and  potassium  chlorate 
is  doubtful. 

But  attention  is  now  widely  drawn  to  the  bichloride  of  mercury,  which 
by  common  consent  is  more  destructive  to  microorganisms,  when  em- 
ployed locall}"^,  than  any  other  agent  that  can  be  safely  used.  Physi- 
cians in  search  for  a  remedy  that  would  destroy  micrococci  in  the  system 
and  thus  remove  the  cause  of  diphtheria  were  naturally  led  to  make  trial 
of  this  agent  in  the  hope  that  an  antidote  or  specific  had  been  found. 
If  the  bichloride  can  be  safely  administered  in  doses  sufficiently  large, 
there  is  every  reason  to  suppose  that  it  will  destroy  the  microbe,  in  the 
interior  of  the  body  as  Avell  as  upon  its  surface.  If  clinical  experience 
show  that  it  can  be  used  in  such  doses  without  poisonous  effect,  it  de- 
serves recognition  as  the  specific  for  diphtheria.  If,  without  injury  to 
the  patient,  it  act  promptly  enough  to  kill  the  microbe  before  serious 
organic  changes  have  occurred  in  the  organs,  as  granulo-fiitty  degenera- 
tion of  the  muscular  fibres  of  the  heart,  or  nepliritis,  it  would  save  many 
lives  and  become  as  important  a  remedy  for  diphtheria  as  quinine  is  for 
diseases  produced  by  marsh  miasm.  But  unfortunately  we  have  to  deal 
with  an  agent  long  recognized  as  a  deadly  poison,  and  it  is  a  problem 
yet  to  be  solved  whether  it  would  not  destroy  the  patient  if  employed 
in  doses  sufficient  to  destroy  the  micrococci.  A  strong  argument  in 
favor  of  this  use  of  the  bichloride  was  presented  to  the  profession  by 
Dr.  Thallon,^  of  Brooklyn.     His  argument  was  substantially  as  follows: 

It  has  been  shown  that  the  bichloride  of  mercury  destroys  the  bacteria 
in  a  li([uid  having  20,000  times  its  weight.  Now,  if  20,000  grains  of 
blood  are  disinfected  by  one  grain  of  the  bichloride,  7000  or  one  pound 
are  disinfected  by  one-third  of  a  grain.  Prof  Flint,  Jr.,  states  that, 
although  the  proportionate  quantity  of  blood  in  the  system  varies  in  dif- 
ferent individuals,  it  may  be  assumed  that  on  the  average  it  is  in  the 
pi'oportion  of  one  to  eight  of  the  entire  weight  of  the  body.  Therefore 
one  grain  of  the  bichloride  would  destroy  the  microbes,  and  disinfect 
the  blood,  in  a  child  weighing  twenty-four  pounds,  two  grains  in  one 
weighing  forty-eight  pounds.  But  if  the  bichloride  can  be  safely  ad- 
ministei'ed  to  a  child  in  such  doses  that  its  system  contains  one  or  two 
grains,  still  it  must  be  remembered  that  in  diphtheritic  systemic  poison- 
ing micrococci  occur  in  the  lymphatics  and  the  tissues,  and  therefore  a 
considerably  larger  quantity  of  the  bichloride  is  necessary  to  produce 
comj)letc  disinfection  than  the  quantity  which  is  recpiired  to  disinfect  the 
blood. 

But  whether  the  bichloride  administered  internally,  is  a  safe,  efficient, 
and  proper  remedy  for  diphtheria  must  be  determined  by  experience. 
If  it  be  shown  to  be  such  by  clinical  observations,  it  should  of  course  be 
administered  in  all  cases,  whatever  be  the  seat  of  the  inHammation.  It 
should  be  administered  in  the  croup  of  diphtheria,  since  if  Ave  remove  the 
cause,  the  inflammation  Avill  abate  or  can  be  more  successfully  treated. 

1  N.  Y.  Jour,  of  Medicine,  April,  1884. 


IXTEEXAL    DISIXFECTAXTS    OR    GERMICIDES.  587 

A  considerable  number  of  observations  have  been  made  in  the  last 
vear  showing  that  adults  badly  tolerate  large  doses  of  the  bichloride. 
Thus  one-twentieth  of  a  grain  administered  hourly  to  an  adult  with 
plithisis  till  seven  or  eight  doses  were  given  each  day  produced  bloody 
diarrhoea  at  the  close  of  the  third  day,  when  about  one  grain  had  been 
taken.  The  same  result  followed  in  another  adult  when  one-twentieth 
of  a  grain  had  been  administered  every  second  hour  in  the  daytime  only, 
for  four  days.  In  a  third  patient  one-twentieth  of  a  grain  given  hourly 
in  the  daytime  for  five  days  caused  profuse  salivation  and  pain  in  the 
gums  like  that  from  calomel.  A  fourth  adult  patient  took  one-thirty- 
second  of  a  grain  hourly  for  eleven  hours,  and  then  one-twenty-sixth  of 
a  grain  for  seven  hours,  Avhen  griping  pain  in  the  abdomen  occurred, 
and  liquid  stools.  (Dr.  A.  H.  Smith.)  One  adult  case  only  is  related 
in  the  experiments  of  Dr.  Smith,  in  which  no  ill-effects  followed  the 
administration  of  one-twentieth  of  a  gi-ain  doses  of  the  bichloride  though 
administered  hourly  in  the  daytime  for  eight  days.  Cases  might  be 
mentioned  in  the  practice  of  other  physicians,  showing  that  the  bichlo- 
ride is  a  dangerous  remedy  if  given  in  germicide  doses  in  the  treatment 
of  adults.  In  one  instance  in  my  practice  bloody  diarrhoea  occurred  on 
the  fourth  day  from  the  uterine  douche  used  three  or  four  times  daily, 
and  fatal  cases  have  been  announced  in  the  journals  from  the  douche. 

But  children  seem  to  tolerate  the  bichloride  better  than  adults,  as 
they  do  arsenic.  It  has  been  largely  used  during  the  last  year  in  New 
York  as  a  remedy  for  diphtheria,  and  especially  for  diphtheritic  croup, 
and  physicians  of  experience  state  that  more  patients  have  recovered 
from  croup  under  treatment  by  the  bichloride  than  from  any  other 
medication  which  they  had  previously  employed.  (Jacobi.)  The  fol- 
lowing brief  statement  of  the  effects  of  the  bichloride  treatment  in  diph- 
theria and  croup  in  a  few  cases  in  the  practice  of  Drs.  Thallon,  Armor, 
Skene,  Jacobi,  and  myself  will  aid  to  an  understanding  of  the  therapeutic 
value  of  this  agent  in  pseudo-membranous  inflammations. 

Case. — A  child  of  6}  years,  having  diphtheria  after  scarlet  fever,  took 
gr.  -5  J  hourly,  most  of  the  time  for  one  week,  and  subsequently  the  same 
dijse  hourlv  in  the  daytime,  and  two  or  three  tiuies  at  night,  with  no  un- 
fjivorable  symptoms;  hut  the  urine  was  increased  to  70  ounces.  A  child 
of  4  years,  having  croup,  coinnlieating  diphtheria,  and  with  urgent  symp- 
toms, took  gr.  -^^  of  the  bichhjride  every  hour  and  a  half  to  three  hours. 
In  five  and  a  half  days  she  took  more  than  two  grains,  and  in  one  day 
more  than  half  a  grain.  Portions  of  the  pseudo-membrane  were  expec- 
torated, and  the  patient  recovered.  There  were  no  unfavorable  symptoms 
from  the  bichloride. 

Of  five  children  who  recovered  from  the  ordinary  form  of  dij)htheria 
reported  bv  different  observers,  one,  aged  1)  years,  t(»ok  gr.  ^  every  one 
and  a  half  hours,  and  in  one  day  nearly  half  a  grain,  till  the  fiftli  day, 
when  a  little  over  two  grains  had  been  taken.  The  second  child,  also 
aged  9  years,  took  nearly  onc-lialf  grain  of  the  bichloride  in  the  first 
twenty-four  hours,  and  in  two  days,  three-quarters  of  a  grain.  The 
third  patient,  aged  4\  years,  took  gr.  J,y  of  tlie  bichloride  every  two 
hours  on  the  first  day,  and  afterwards  at  l(jnger  intervals.     In  the  fourth 


588  MEMBRAXOUS    CROUP. 

case,  a  child  of  7|  years,  gr.  ^^j  was  given  every  tvro  hours,  for  how 
long  is  not  stated,  but  the  membrane  became  less  on  the  second  day. 
The  fifth  patient,  aged  2  years  5  months,  had  a  hoarse  whispering  voice 
and  noisy  (guttural)  respiration  ;  temperature  105°.  The  pseudo-mem- 
brano  appeared  over  the  tonsil  in  considerable  quantity  at  the  close  of 
the  second  day.  The  bichloride,  gr.  J^-,  was  given  every  second  hour 
alternately  with  six  minims  of  tlie  tincture  of  tlie  chloride  of  iron.  Al- 
kaline inhalations  were  constantly  used,  and  one  teaspoonful  of  brandy 
given  every  two  hours.  The  bichloride  was  administered  three  days 
with  no  appreciable  ill-effect,  and  with  gradual  improvement  of  the 
patient. 

Although  during  the  last  few  months  the  bichloride  has  been  largely 
used  as  a  remedy  for  diplitheria  and  pseudo-membranous  croup,  in  doses 
like  those  employed  in  the  above  cases,  but  few  instances  have  been 
published  in  which  it  seemed  to  disagree.  It  has,  however,  in  some 
patients  caused  diarrhoea,  and  apparently  colicky  pains,  as  in  adults,  so 
that  it  was  deemed  advisable  to  discontinue  its  further  use.  Accordincr 
to  rav  observation  it  does  not  save  life,  or  materialiv  mitigate  the  inten- 
sity  of  the  disease,  or  the  inllaunnation,  if  profound  blood-poisoning,  or 
grave  complications,  as  nephritis,  have  occurred  when  its  employment 
is  commenced. 

The  following  cases,  among  others  which  have  come  under  my  obser- 
vation, show  that  the  bichloride  if  administered  in  grave  cases  at  a  late 
stage  is  powerless  to  save  life:  A  child  of  oh  years,  Avith  malignant  diph- 
theria, took  at  first  the  ordinary  remedies,  such  as  iron  and  potassium 
chlorate,  and  when  the  urine  had  become  heavily  albuminous,  and  the 
fauces  much  swollen  and  covered  with  a  dense  and  foul  2:)seudo-membrane, 
the  bichloride  was  prescribed  in  hourly  doses  of  gr.  ^.  Two  days  later 
death  occuri'ed,  apijarently  from  the  blood-poisoning.  Another  patient 
of  the  same  ago,  and  nearly  the  same  history,  lived  four  days  under  the 
bichloride  treatment.  Perhaps  better  results  might  have  occurred  from 
its  earlier  use. 

Clinical  observations  will  soon  determine  the  actual  value  of  the 
bichloride  in  the  treatment  of  diphtheria  and  diphtheritic  inflamma- 
tions ;  and  if  it  be  a  safe  and  useful  remedy,  whether  its  beneficial 
effects  are  due  to  its  germicide  action,  or  to  the  same  therapeutic 
effects  as  those  obtained  from  other  mercurial  agents.  It  may  be  con- 
veniently prescribed  in  the  foUowing  formulae  recommended  by  Pepper 
and  Thallon  : 

R . — Hydrari;.  bichlor pr.  ss. 

Tine,  fcni  chloridi  ....     f.^iij- 

Glycerinae        .         .         .         .         .         .     f^ss. 

Aqu*      .         .         .         .         .         .         .     q.  s.  ad  f^iij. — Misce. 

One  teaspoonful  every  liour  to  two  hours. 

R. — Tlydrarg.  bichlor.    .....     gr.  ss. 

Elix    bismiitlii, 

Vini  pepsin i   ......     aa  ^iss. — Misce. 

One  teaspoonful  every  hour  to  two  hours. 

It  does  not  seem  necessary  or  prudent  in  ordinary  cases  to  continue 
the  use  of  the  bichloride  more  than  three  or  four  days  in  large  and  fre 
Quent  doses. 


SURGICAL    TREATMENT.  589 

Since  membranous  croup  in  localities  where  diphtheria  prevails  is  in 
most  instances  a  local  manifestation  of  this  disease,  the  same  sustaining 
general  treatment  is  required  which  is  proper  in  ordinary  cases  of 
diphtheria.  The  tincture  of  the  chloride  of  iron,  administered  every 
second  hour  in  liberal  doses,  potassium  chlorate,  quinine,  brandy  or 
other  form  of  alcohol  in  large  and  frequent  doses,  long  used  in  diph- 
theria as  tonics  and  blood  restorers,  are  indicated.  Medicines  of  this 
kind  may  be  given  between  those  which  are  designed  to  coiTcct  the 
exudative  process,  and  aid  in  removing  the  laryngeal  obstruction,  and 
which  Jiave  been  described  above.  The  diet  should  be  nutritious  and 
easily  digested,  consisting  largely  of  milk  and  the  meat  teas.  For 
those  with  poor  appetite  and  feeble  digestion,  peptonized  milk,  and  the 
peptonized  meat  juices  may  often  be  advantageously  prescribed. 

Surgical  Treat.mext. — Although  the  best  possible  treatment  by 
inhalations  and  internal  medication  be  early  employed  and  Avithout 
intermission,  yet  it  is  the  common  experience  in  all  countries  that  such 
treatment  is  in  a  large  proportion  of  cases  inadequate,  and  that  many 
perish  from  suffocation  unless  relieved  by  surgical  interference.  We 
have  stated  above,  that  if  croup  occur  at  the  commencement  of  diph- 
theria when  the  exudative  -process  is  active,  and  the  pseudo-membranes 
form  rapidly  and  abundantly,  death  is  the  common  result,  if  medicinal 
treatment  only  be  employed.  But  if  the  inflammation  be  less  intense 
or  subacute,  as  in  the  second  week  of  diphtheria,  so  that  there  is  more 
time  for  the  action  of  medicines  and  inhalations,  and  if,  as  is  sometimes 
the  case,  the  stenosis  appear  to  be  at  a  stand-still,  without  any  marked 
suffering  from  want  of  air,  resort  to  surgical  measures  may  be  judiciously 
postponed. 

The  indications  for  surgical  interference  are  a  gradual  increase  of  the 
stenosis  and  consequent  dyspnoea,  notwithstanding  the  constant  and 
judicious  use  of  remedial  agents,  and  a  manifest  suifering  from  want  of 
air  as  shown  by  restlessness  of  the  child,  and  the  expression  of  suffering 
in  his  features,  with  or  without  lividity  of  the  surface.  We,  adults,  may 
have  some  faint  conception  of  the  suffering,  Avhich  children  with  acute 
laryngeal  stenosis  undergo,  when  Ave  have  severe  nasal  catarrh  and 
attempt  to  breathe  Avith  the  mouth  closed,  and  the  paramount  duty  of 
the  physician  to  relieve  suffering  should  prompt  to  a  resort  to  other 
measures  Avhcn  medicines  prove  inadequate,  even  if  Ave  leave  out  of 
account  the  important  object  of  saving  life.  When  therefore  membra- 
nous croup  is  found  to  be  progressive  after  having  been  observed  and 
properly  treated  from  six  to  twenty-four  hours,  and  the  child  begins  to 
suffer  from  want  of  air,  the  propriety  of  surgical  interference  should  be 
considered. 

TuDAfJE. — Tn  1858,  Bouchut'  published  a  paper  on  a  new  method  of 
treating  croup  by  tubage  of  the  larynx.  lie  employed  a  straight  cylin- 
drical tube  nearly  an  inch  long.  The  tube  Avas  introduced  by  means 
of  a  male  catheter  open  at  its  two  ends.  Tubage  excited  some  attention 
and  discussion  at  the  time  in  the  Parisian  capital,  and  M.  Gros  related 
a  case  of  its  successful  employment.     It  was  found  in  experiments  on 

'  Moniteur  des  H6pit. 


590  MEMBRANOUS   CROUP. 

animals  that  the  tube  caused  ulcerations,  and  as  it  did  not  produce  the 
uniform  relief  which  follows  tracheotomy,  and  was  discountenanced  by 
Trousseau,  Barthez,  and  others,  it  fell  into  disuse,  and  was  abandoned 
as  a  substitute  for  tracheotomy  even  by  those  who  at  first  warmly  advo- 
cated it.  Recently  Dr.  0.  Dw\an-,  of  the  New  York  Foundling  Asy- 
lum, has  devised  a  tube  of  about  the  same  length,  but  differing  from 
that  of  Bouchut,  in  having  a  greater  antero-posterior  than  lateral 
diameter,  and  therefore  conforming  to  the  shape  of  the  laryngeal  aper- 
ture. The  left  index  finger,  guarded  by  a  broad  metallic  ring,  is  car- 
ried far  back  in  the  mouth  of  the  patient  so  as  to  depress  the  root  of 
the  tongue  aiul  raise  and  fix  the  ej)iglottis,  and  the  tube  is  introduced 
by  a  curved  handle,  attached  to  its  inner  surface ;  the  handle  is  de- 
tached by  a  spring.  The  tube  can  be  readily  removed  by  attaching  the 
handle  to  the  same  fiistening  on  its  inner  surface.  Tubing  as  thus  em- 
ployed usually  relieves  laryngeal  stenosis,  and  I  am  not  aware  that  the 
instrument  of  Dr.  0.  Dwyer,  although  employed  in  a  considerable  num- 
ber of  instances,  has  produced  ulceration  or  other  injury  of  the  larynx. 

Case. — On  May  21,  1884,  during  my  term  of  service  in  the  New  York 

Foundling  Asylum,  Florence- ,  oj  years,  was  admitted  at  the  time 

of  my  visit,  suffering  from  extreme  dyspnoea.  The  symptoms  of  acute 
laryngeal  stenosis  were  so  pronounced,  such  as  great  depression  at  the 
summit  and  base  of  the  chest  on  insj)iration,  restlessness,  and  the  appear- 
ance of  anguish  in  the  features  from  want  of  air,  that  the  child  apparently 
could  not  live  more  than  two  or  three  hours  without  relief.  The  fauces 
were  somewhat  hypemeniic,  but  without  pseudo-membrane.  The  tube  was 
applied  l)y  Dr.  O.  Dwyer,  with  immediate  relief  of  the  dyspnoea,  and  the 
expectoration  of  a  large  (Uianlity  of  muco-pus.  Liquid  food  was  readily 
swallowed  when  the  tube  was  present,  but  occasionally  some  of  it  entered 
the  air-passages,  provoking  a  cough.  Three  hours  after  the  insertion  of 
the  tube  the  axillary  temperature  was  102"^.  22d.  Breathing  still  easy; 
axillary  temp.  lOo^ ;  pulse  130.  23d.  Tlie  tube  has  given  complete  relief; 
a  small  pseudo-membrane  exists  on  each  side  between  the  uvula  and  ton- 
sils. 28th.  The  tube  was  expectorated  to-day,  and  as  the  respiration 
remained  normal  without  the  tube,  it  was  not  replaced.  80th.  Temp. 
99p  ;  pulse  136,  at  times  as  low  as  80;  has  a  loose  cough.  "When  the 
tube  was  worn  and  immediately  afterwards  she  expres-^ed  her  wants  in  a 
feeble  whisper,  which  could  be  understood  even  when  the  vocal  cords 
were  covered  by  the  tube.  The  voice  gradually  returned  after  the  expul- 
sion of  the  tube,  and  no  further  treatment  was  required.  The  suffering 
of  the  patient  was  quickly  relieved,  and  her  life  ajoparently  saved  by 
tubage. 

The  tube  when  in  situ  does  not  produce  a  cough,  or  apparently  any 
unpleasant  sensation  in  the  larynx.  Tubage  would  in  my  opinion 
come  into  general  use  as  a  substitute  for  tracheotomy,  were  it  not  for 
the  fact  that  the  pseudo-membrane  in  so  large  a  proportion  of  cases 
extends  beyond  the  larynx,  and  the  tube  fails  to  relieve  tracheal  and 
bronchial  obstruction.  Since  tracheotomy  gives  equally  prompt  relief 
to  the  d\'spn(ca,  and  in  a  larger  numl)cr  of  cases,  and  enables  us  to 
remove  the  obstruction  from  the  ti-acliea,  and  to  a  certain  extent  from 
the  bronchial  tubes  through  the  artificial  opening,  the  almost  universal 


TRACHEOTOMY.  591 

opinion  in  both  continents  that  it  is  preferable  to  tubage  or  any  other 
surgical  measure,  has  a  valid  foundation.  Usually  it  is  best  not  to  defer 
tracheotomy,  in  order  to  make  the  uncertain  trial  of  tubage,  when  the 
symptoms  are  so  urgent  that  surgical  measures  are  required. 

Tracheotomy. — Since  diphtheria  has  spread  so  widely,  tracheotomy 
has  become  one  of  the  most  important  operations  in  sui'gery.  Properly 
performed,  and  at  the  proper  time  with  judicious  after-ti-eatment,  it 
rescues  many  children  from  a  most  painful  death.'  The  details  of  this 
operation  are  given  in  surgical  treatises,  but  some  general  remarks  re- 
lating to  it  will  not  be  inappropriate  here. 

Sanne  says  that  the  operator  should  have  three  assistants,  at  least 
one  of  them  a  physician.  One  should  administer  chloroform,  one  use 
the  sponge,  and  the  third,  a  physician,  should  be  ready  to  assist  in 
handing  instruments,  ligating  vessels,  etc.  "Tlie  operation  is  simple  and 
devoid  of  danger,  or  difficult  and  dangerous,  according  to  circumstances. 
The  younger  the  child,  the  greater  the  danger,  other  things  being  equal. 
The  greatest  difficulty  and  risk  attend  tracheotomy  in  fleshy  infimts  with 
thick  and  short  necks,  and  in  patients  who  have  extreme  dyspnoea,  and 
are  nearly  moribuml.  so  that  the  operator  is  impelled  to  hurry  in  the 
operation  through  fear  that  death  will  occur  before  the  trachea  is  opened. 
The  operator  should  have  time  for  slow  and  cautious  dissection,  that  he 
may  avoid  wounding  vessels  and  other  important  parts. 

The  patient  to  be  operated  on  should  be  placed  on  his  back  on  a  table 
covered  by  a  blanket,  and  a  bottle  or  block  about  four  inches  in  diameter 
should  be  placed  under  his  neck,  so  that  the  h6ad  is  thrown  back  at  an 
angle  of  forty-five  degrees,  and  the  anterior  surface  of  the  neck  rendered 
prominent.  Chloroform  is  then  administered.  An  incision  should  be 
made  through  the  skin  in  the  median  line  one  and  a  half  to  two  inches 
in  length,  according  to  the  age,  and  extending  to  within  half  an  inch  of 
the  sternum.  Through  the  connective  tissue  to  the  trachea  the  dissec- 
tion should  be  slowly  and  cautiously  made  with  the  point  of  the  knife, 
the  scissors,  and  the  blunt  hooks  which  are  used  to  tear  the  connective 
tissue  and  draw  aside  vessels.  The  tip  of  the  finger  occasionally  pressed 
upon  the  trachea  aids  in  determining  its  location,  and  serves  to  guide 
the  dissection,  which  should  always  be  in  the  median  line.  Little  cut- 
ting is  required  after  the  skin  has  been  divided,  but  when  fi])res  of  con- 
nective tissue  resist  the  blunt  hooks,  they  should  be  cut  either  by  tlir 
point  of  the  knife  or  the  scissors.  A  grooved  director  is  also  useful  in 
the  dissection,  since  by  it  the  operator  is  enabled  to  raise  ami  tear  re- 
sisting fibres,  or  detach  them  from  parts  underneath,  so  that  they  can 
be  more  readily  divided. 

Some  surgeons  prefer  the  high,  others  the  low  operation  In  the 
high  operation  the  trachea  is  found  nearer  the  surface,  and  the  vessels 
in  the  way  are  less  numerous  than  in  the  low  operation.  In  the  opera- 
tion, however,  the  trachea  is  usually  opened  at  that  point,  whether  high 
or  low,  which  is  most  readily  reached  and  laid  bare.  When  this  tul)e 
is  exposed  a  longitudinal  incision  is  made  through  its  anterior  wall  suffi- 
ciently long  to  allow  the  canula  to  be  inserteil.  It  facilitates  opening 
tlie  trachea  if  it  be  held  by  a  tenaculum  constructed  for  the  purpose  with 
the  hook  bent  so  as  to  be  at  right  angles  with  the  handle.     The  length 


592  MEMBRANOUS    CROUP. 

af  the  incision  through  the  trachea  shouhl  be  about  five-eighths  of  an 
inch.  The  canuhi  should  not  be  immediately  introduced,  but  the  patient 
should  be  made  to  cough  by  inserting  a  pigeon's  quill  down  the  trachea 
into  the  bronchial  tubes.  Blood,  muco-pus,  and  shreds  of  fibrin,  if  any 
be  present,  are  expelled  through  the  opening  by  the  cough  Avhich  the 
quill  produces.  The  canula  is  now  introduced  with  or  without  the  aid 
of  the  tracheal  dilator.  The  one  which  is  in  common  use  is  that  devised 
by  Trousseau,  with  some  subsequent  improvements.  It  consists  of  two 
concentric  cylinders,  the  external  fenestrated,  and  the  disk  or  plate 
which  supports  the  tubes  is  movable  upon  them. 

The  result  depends  to  a  great  extent  on  the  subsequent  treatment. 
The  common  result  is  immediate  relief  to  the  dyspnoea,  but  unfortu- 
nately in  a  large  proportion  of  cases  the  temperature  rises  about  the 
third  day  after  the  operation,  and  pseudo-membranes  begin  to  form  in 
the  bronchial  tubes,  and  in  some  instances  broncho-pneumonia  results. 
Surgeons  have  endeavored  to  prevent  the  formation  of  membranes  in 
the  bronchial  tubes  after  tracheotomy  by  allowing  lime-water  to  trickle 
through  the  aperture  into  the  tubes.  Perhaps  some  other  solvent  of 
pseudo-membranes,  as  bicarbonate  of  soda  or  trypsine,  might  be  prefer- 
able for  this  purpose.  No  surgical  operation  more  imperatively  requires 
intelligent  and  attentive  after-nursing  than  tracheotomy,  since  the  canula 
needs  to  be  frequently  removed  and  cleaned  whenever  obstructed  by  muco- 
pus.  The  febrile  movement  alluded  to  above  as  indicating  the  extension 
of  the  inflammation  downwards  in  the  tubes  may  be  in  a  measure  relieved 
by  the  application  around  the  chest  of  one  or  two  thicknesses  of  muslin 
wrung  out  of  cool  water  and  covered  by  oil  silk.  No  certain  time  can  be 
foretold  for  the  removal  of  the  canula  if  the  patient  live.  If  on  withdraw- 
ing the  inner  tube  and  applying  the  finger  over  the  end  of  the  remaining 
canula,  the  patient  breathe  easily  through  fenestra,  tlie  laryngeal  stenosis 
has  probably  so  far  abated  that  the  tube  can  be  safely  removed. 

The  following  is  a  description  of  the  instruments  in  the  tracheotomy 
case  of  one  of  the  most  skilful  operators  in  New  York  City,  Dr.  Fred. 
Lange.     All  of  them  have  small  handles  like  those  of  dental  instruments. 

1.  a.  A  scalpel,  with  cutting  edge  convex,  the  blade  1 J  inches  in 
length,  and  its  greatest  width  J  inch.  This  scalpel  is  employed  in 
dividing  the  skin  and  in  the  subsequent  dissection,  h.  A  scalpel  of 
same  length,  but  with  narroAver  blade  and  straij2;ht  cutting  edire,  used 
for  opening  the  trachea. 

2.  Two  blunt  hooks,  with  the  hook  straight,  |-  inch  in  length,  extend- 
ing at  a  right  angle  from  the  handle,  having  a  diameter  scarcely  larger 
than  a  car|)et  needle.  The  end  of  the  hook  is  slightly  bulbous.  A 
considerable  part  of  the  dissection  is  performed  by  the  blunt  hooks 
which  are  used  in  tearing  the  connective  tissue. 

3.  Three  artery  clamps,  by  Avhich  bleeding  vessels  or  oozing  surfaces 
are  seized,  and  the  instruments  Avith  their  points  attached  to  the  bleed- 
ing surfaces  are  dropped  upon  the  sides  of  the  neck.  They  thus  aid  in 
drawing  open  the  Avound. 

4.  Tenacula.  Two  Avith  hooks  in  line  Avith  the  handle;  tAvo  others 
with  hooks  at  right  angle  to  the  handle ;  the  diameter  of  the  curves  in 


BR0XCH1TI3.  593 

the  hooks  ^  inch.      Those  wich  hooks  at  right  angles  are  employed  for 
transfixing  and  holding  the  trachea  when  it  is  to  be  opened. 

5.  Two  grooved  directors,  one  with  the  end  smaller  and  more  pointed 
than  that  of  the  other. 

6.  A  common  artery  forceps,  also  forceps  with  fine  teeth. 

7.  The  spring  hook  of  the  oculist,  employed  by  him  in  separating 
the  eyelids;  it  holds  apart  the  edges  of  the  w^ound. 

8.  The  tracheotomy  tube  consisting  of  two  concentric  cylinders,  de- 
scribed above. 

9.  Pigeon's  quills ;  these  are  important  for  removing  muco-pus  and 
fibrinous  shreds  from  the  trachea  and  bronchial  tubes.  An  instance 
has  come  to  my  knowledge  in  which  the  physician  who  assumed  charge 
of  the  case  after  the  operation  attempted  to  use  for  this  purpose  a  small 
piece  of  sponge  held  by  forceps ;  he  unfortunately  loosened  his  hold, 
and  the  sponge  drawn  in  Avith  the  breath  produced  immediate  death  by 
suffocation.     This  Avould  not  have  happened  Avith  the  pigeon's  quill. 

When  the  operation  is  completed  and  the  canula  introduced,  iodoform 
should  be  dusted  upon  the  wound,  and  two  thicknesses  of  linen  soaked 
with  the  solution  of  bichloride  of  mercury,  one  part  to  two  thousand, 
notched  so  as  to  surround  the  canula  and  pass  under  its  plates,  should 
be  applied  over  the  Avound,"  and  every  hour  moistened  Avith  the  bichloride 
solution.  With  such  treatment  the  wound  preserves  a  healthy  appear- 
ance and  heals  readily. 


CHAPTER  lY. 

BRONCHITIS. 

Inflammation  of  the  bronchial  tubes,  or  bronchitis,  is  probably  the 
most  frequent  disease  of  early  life.  It  is  usually  associated  with  more 
or  less  inllammation  of  the  mucous  membrane  of  the  nostrils,  larynx, 
and  trachea.  We  designate  the  disease  coryza,  laryngitis,  or  bronchitis, 
according  as  one  or  the  other  inllammation  predominates.  Sometimes 
bronchitis  occurs  Avith  but  slight  inllammation  elscAvhere,  and  often  the 
coryza  and  laryngitis  abate  Avhile  the  bronchitis  is  still  active. 

Bronchitis  occurs  both  as  a  primary  and  secondary  disease.  The 
secondary  form  is  common  in  connection  with  measles,  hooping-cough, 
pneumonia,  and  pulmonary  phthisis,  and  it  is  not  uncommon  in  remit- 
tent and  continued  fevers.  Bronchitis  is  acute,  subacute,  or  chronic, 
and  according  to  its  extent  it  is  mild  or  severe.  If  the  smallest  bron- 
chial tubes  are  involved,  the  inflammation  is  designated  capillary  bron- 
chitis, a  term  not  Avell  chosen,  but  Avhich  is  conveniently  employed 
in  a  description  of  the  malady.  Bronchitis  is  commonly  bilateral, 
affecting  the  tubes  on  the  tAvo  sides  with  about  equal  intensity.    When 

88 


594  BRONCHITIS. 

due  to  tubercles,  or  to  pneumonia,  it  is  often  unilateral,  being  confined 
to  those  tubes  or  nearly  to  those  Avhich  are  surrounded  by  tubercular 
or  inflammatory  product. 

Causes. — The  causes  of  secondary  bronchitis  are  obviously  the  dis- 
eases in  connection  with  which  it  occurs.  Tlie  cause  of  primary  bron- 
chitis is  the  same  as  that  of  simple  acute  laryngitis  or  coryza,  namely, 
sudden  change  of  temperature  from  Avarm  to  cold,  exposure  to  currents 
of  air,  the  practice  of  sending  children  without  sufficient  clothing  from 
heated  rooms  into  the  open  air,  the  throwing  off  of  bedclothes  at  night, 
etc.  Dentition  is  also  an  occasional  cause,  since  some  children  have 
attacks  which  coincide  Avith  the  eruption  of  the  teeth.  The  cough  of 
dentition  is  usually  purely  a  nervous  affection  ;  but  in  other  instances  it 
is  accompanied  by  more  or  less  mucous  secretion,  and  is  evidently  de- 
pendent on  a  mild  catarrh. 

Anatomical  Characters. — In  the  most  common  form  of  bronchitis 
the  larger  bronchial  tubes  only  are  affected.  They  are  the  seat  of  the 
inflammation  in  most  of  those  cases  Avliich  are  designated  "colds"  by 
families,  and  which  are  often  treated  Avithout  the  aid  of  the  physician. 
The  lining  membrane  of  the  bronchial  tubes  presents  the  ordinary  ana- 
tomical characters  of  mucous  inflaunnations.  It  is  reddened  uniformly 
or  in  patches  intensely,  or  in  that  milder  degree  known  as  arborescence, 
according  to  the  severity  of  the  inflammation. 

The  secretion  of  the  muciparous  follicles  is  at  first  arrested,  and  the 
surface  of  the  membrane  is  dry.  In  the  course  of  a  day  or  two  the 
secretory  function  is  reestablished,  and  the  surface  is  covered  with  thin 
and  transparent  mucus.  A  day  or  tAvo  later,  the  secretion  becomes 
thicker,  consisting  of  mucus  and  pus.  Mixed  Avith  these  substances  are 
epithelial  cells,  which  are  exfoliated  in  abundance  from  the  inflamed 
surface.  At  the  same  time  the  mucous  membrane  becomes  thickened 
and  more  or  less  softened.  If  the  inflammation  be  severe,  the  vessels 
of  the  submucous  connective  tissue  are  also  injected. 

Usually,  in  about  a  Aveek  in  the  young  child,  in  from  one  to  two 
weeks  in  older  children,  the  inflammation  begins  to  abate.  Gradually 
the  inflamed  memJjrane  returns  to  its  normal  consistence,  thickness,  and 
vascularity,  and  Avith  this  return  to  the  healthy  state  the  muco-purulent 
secretion  abates. 

In  this,  Avhich  is  the  simplest  and  most  common  form  of  bronchitis, 
there  is  no  ulceration,  and  rarely  any  pseudo-membranous  formation,  if 
the  disease  be  idiopathic.  Pseudo-membranous  bronchitis  is  not  unusual 
as  an  accompaniment  of  pseudo-membranous  laryngo-tracheitis. 

Were  bronchitis  limited  to  the  larger  bronchial  tubes,  it  would  indeed 
be  a  simple  affection,  but  unfortunately  it  has  a  tendency  to  extend 
downward.  Commencing  in  the  larger,  it  gradually  invades  the  smaller 
tubes  in  a  similar  manner  to  the  extension  of  erysipelas  upon  the  skin. 
More  rarely  the  inflammation  commences  simultaneously  in  the  larger 
and  smaller  tubes.  Now  the  gravity  of  bronchitis  is  proportionate  to 
the  degree  of  its  extension  doAvuAvard.  It  may  stop  at  any  point  in  its 
progress,  but  if  it  reach  the  smaller  tubes  it  is  one  of  the  most  serious 
affections  of  early  life. 

The  mucous  membrane  of  the  minute  tubes,  those  next  to  the  air- 


ANATOMICAL    CHARACTERS.  595 

cells,  is  delicate,  with  but  little  submucous  connective  tissue,  and  it  fre- 
quently, at  post-mortem  examinations,  does  not  present  to  the  eye  those 
distinct  inflammatory  changes  which  are  observed  in  tubes  of  large 
diameter.  It  is  sometimes  not  notably  thickened,  nor  its  vascularity 
much  increased,  even  when  there  is  reason  to  believe  from  the  symptoms 
that  it  was  the  seat  of  active  phlegmasia.  As  we  pass  from  these  minute 
tubes  to  those  of  larger  calibre,  the  inflammatory  lesions  become  more  dis- 
tinct. The  inflammation  produces  minute  and  abundant  points  of  redness 
and  the  membrane  is  evidently  thickened;  often  it  is  rough  or  granular. 

The  minute  bronchial  tubes  are  very  small,  especially  under  t!ie  age 
of  three  years,  and  since  in  capillary  bronchitis  a  large  proportion  of 
them  are  inflamed,  the  source  of  the  danger  is  apparent.  It  is  with 
difficulty  that  the  patient  with  capillary  bronchitis  can,  by  the  effort  of 
coughing,  free  the  tubes  from  the  secretions  which  are  constantly  col- 
lecting in  them.  In  weakly  children,  under  the  age  of  two  years,  ex- 
pectoration is  most  difficult,  and  hence  the  great  and  increasing  dyspnoea 
from  which  such  patients  suffer. 

In  severe  and  unfiivorable  cases  of  bronchitis,  which  are  chiefly  those 
in  which  the  small  as  well  as  large  tubes  are  inflamed,  the  following  ana- 
tomical changes  commonly  occur:  The  muco-purulcnt  secretion,  which 
is  tenacious,  collects  more  rapidly  in  the  smaller  tubes  than  it  is  expecto- 
rated by  the  child,  whose  strength  begins  to  be  exhausted.  The  accu- 
mulation of  the  secretion  is  chiefly  in  the  tubes  which  lie  in  the  posterior 
and  inferior  portions  of  the  lung.  As  the  obstruction  from  tlie  muco- 
pus  increases  in  these  tubes,  less  and  less  air, passes  through  them  into 
the  alveoli  with  which  they  communicate,  while  the  quantity  of  air  which 
passes  through  the  unobstructed  tubes  into  the  anterior  and  superior 
portions  of  the  lung  is  proportionately  increased.  The  eff'ect,  as  regards 
the  state  of  the  lung,  is  obvious.  In  cases  having  a  flital  issue,  ami  in 
which  we  are  therefore  able  to  inspect  the  lesions,  we  find  that  the  lower 
and  inferior  portions  of  the  organ,  from  which  air  was  to  a  greater  or 
less  extent  excluded,  have  a  diminished  crepitation,  that  they  lie  a  little 
below  the  general  level,  or  that  certain  lobules  do,  and  that  they  present 
a  congested  appearance,  for  while  they  contain  too  little  air  they  have 
an  excess  of  blood.  We  shall  also  find  that  tiie  upper  and  anterior  parts 
of  the  organ,  perhaps  the  entire  upper  lobe,  contain  more  than  the 
normal  quantity  of  air,  so  as  to  rise  above  the  general  level.  Tiiere  is 
distention  of  the  alveoli  in  these  parts,  so  that  they  are  probably  visible 
to  the  naked  eye,  and  may  appear  to  be  emphysematous,  but  this  is  a 
state  distinct  from  emphysema.  It  is  merely  an  inflation  of  the  alveoli 
to  neai-ly  their  full  capacity. 

Here  and  there  in  the  portion  of  lung  in  which  the  inflation  has  been 
incomplete,  lobules  may  be  observed  which  are  entirely  collapsed,  having 
a  dusky  red  color  and  no  crepitation ;  while  in  other  parts,  if  the  bron- 
chitis have  continued  some  days,  there  may  be  nodules  of  pneumonia. 
The  incise<l  surface  of  those  portions  of  the  lung  to  which  the  access  of 
air  has  been  prevented,  whether  they  are  collapsed  fully,  or  partially  or 
not,  has  a  reddish  color  from  congestion,  and  is  moist  from  serum  and 
blood.  On  compressing  the  lung,  the  muco-purulent  secretion  appears 
upon  the  surface  in  points,  having  escaped  from  the  divided  ends  of  the 


596  BROXCHITIS. 

tubes.  For  otlicr  facts  relating  to  atelectasis,  the  reader  is  referred  to 
the  chapter  in  which  this  malady  is  described. 

Exceptionally  even  when  not  accompanied  by  laryngeal  croup,  filjrin- 
ous  exudation  occurs  in  the  bronchial  tubes,  forming  a  delicate  film, 
here  and  there,  and  readily  dctaclied  from  the  surf  ice  umlerneath,  Avhile 
in  rare  instances  it  occurs  as  a  firm  and  continuous  membrane,  forming 
a  mould  of  the  tubes,  increasing  greatly  the  dyspnoea,  and  constituting  a 
true  bronchial  croup.  If  the  patient  with  severe  bronchitis  survive,  the 
inflammation  of  the  mucous  membrane  soon  begins  to  abate.  The  tubes 
which  have  been  the  seat  of  the  disease,  and  the  alveoli  Avhich  have  been 
secondarily  involved,  may  return  to  their  normal  state  almost  immedi- 
ately; but  in  other  instances  such  anatomical  changes  occur  in  them, 
even  when  there  is  no  pneumonia,  nor  atelectasis,  that  full  restoration 
to  their  normal  state  is  necessarily  somewhat  slow.  When  the  function 
of  a  lobule  ceases,  as  it  does  Avhen  the  tube  leading  to  it  is  obstructed, 
not  only  hyperemia  occurs  with  or  without  collapse,  as  already  stated, 
but  its  cells  and  nuclei,  and  j)erhaps  other  parts,  begin  to  undergo  fatty 
degeneration.  Tiiese  elements  become  granular,  somewhat  enlarged 
and  o))aque,  and  here  and  there  mixed  with  them  are  other  large  cells 
filled  with  oil-globules.  These  are  the  compound  granular  cells  of  path- 
ologists, and,  occurring  in  this  situation,  are  produced  by  metamorphoses 
of  the  epithelial  cells.  They  are  epithelial  cells  which  have  progressed 
more  rapidly  than  others  in  fatty  degeneration,  having  reached  that 
stage  of  it  which  immediately  precedes  liquefaction.  We  often  with  the 
microscope  observe  not  only  these  corpuscles,  but  their  fragments  as 
they  are  dissolving. 

Minute  abscesses,  usually  directly  under  the  pleura,  have  occasionally 
been  ol)served  at  the  autopsies  of  those  who  have  recently  had  general 
bronchitis,  and  pathologists  are  not  agreed  as  to  the  mode  in  which  they 
are  produced.  Some  of  them,  if  not  all,  are  evidently  connected  with 
the  minute  bronchial  tubes,  and  the  quantity  of  pus  contained  in  each 
is  not  usually  more  than  one  or  two  drops.  The  most  reasonable  view 
of  their  causation  is  that  they  are  produced  in  the  terminal  tubes  whei'e 
the  mucus  and  pus  collect.  The  i)us  acts  as  an  irritant  and  causes  in- 
flammation, and  the  inflammation  increases  the  quantity  of  pus.  The 
walls  of  the  tube  which  is  now  the  seat  of  an  abscess  are  destroyed  by 
ulceration,  and  probably,  also,  some  of  the  contiguous  air-cells.  The 
little  cavity  is  soon  surrounded  by  a  delicate  membrane,  the  same  in 
character,  though  less  thick  and  firm,  as  thatAvhich  constitutes  the  walls 
of  larger  abscesses.  The  pus  presents  the  usual  appearance  of  this 
liquid,  or  it  may  be  tinged  by  the  presence  of  blood-cells,  or  again  it 
may  be  thick  from  partial  absorption  of  the  li(|uor  puris  so  as  to  resemble 
softened  tubercle. 

The  abscess  is  ordinarily  located  in  the  centre  of  a  collapsed  lobule. 
In  certain  cases  it  approaches  the  surface  of  the  lungs,  so  as  to  produce 
circumscribed  pleurisy,  with  adhesion  of  the  costal  and  visceral  pleura. 
At  the  autopsy  of  sucii  a  case,  on  separating  the  adhesions  and  attempt- 
ing insufflation,  the  air  passes  through  the  aperture,  so  that  the  lung 
on  that  side  cannot  be  inflated  unless  the  aperture  be  closed.     Occa- 


SYMPTOMS.  597 

sionally  pneumothorax   results   from   opening  of   tlie  abscess    into  the 
pleural  cavity. 

In  severe  protracted  bronchitis  dilatation  of  certain  of  the  bronchial 
tubes  sometimes  results.  The  alveoli  in  the  upper  lobes  may  also  be 
distended  beyond  their  physiological  capacity,  so  as  to  produce  emphy- 
sema, but,  as  we  have  stated  above,  their  maximum  distention  within 
physiological  limits  must  not  be  mistaken  for  emphysema.  Emphysema 
in  the  upper  lobes  is  common  in  feeble  young  children,  with  relaxed  and 
weakened  tissues,  occurring  even  without  any  severe  disease  of  the  re- 
spiratory organs.  It  may  be  vesicular  or  interstitial.  If  it  be  inter- 
stitial the  sacs  of  air  often  attain  considerable  she,  lying  as  wedges 
between  the  alveoli,  or  like  little  bhidders  upon  the  surface  of  the  lung. 
It  is  not  difficult  to  understand  how  emphysema  occurs  in  severe  bi'on- 
chitis,  since  the  air  partly  arrested  in  the  tubes  leading  to  the  lower 
lobes  enters  the  upper  lobes  in  increased  volume  and  force. 

Symptoms. — It  is  evident,  from  the  description  Avhich  has  been  given 
of  the  anatomical  characters  of  bronchitis,  that  its  symptoms  vary  greatly 
in  Severity  in  diflferent  patients.  It  usually  commences  with  more  or 
less  coryza.  The  symptoms  are  headache,  flushed  fiice,  elevation  of 
temperature,  acceleration  and  fulness  of  pulse.  In  the  mildest  cases 
these  symptoms  are  scarcely  appreciable.  The  child  is  observed  to 
sneeze  and  have  some  defluxion  from  the  nostrils,  and  this  is  followed 
by  an  occasional  mild,  almost  painless,  cough,  which  declines  in  the 
course  of  a  few  days.  The  respiration  and  pulse  are  scarcely  acceler- 
ated, and  the  appetite  is  but  slightly  impaired.  There  may  be  a  little 
fretfulness,  but  the  child  is  not  confined  to  his  bed  or  room,  and  usually 
amuses  himself  with  his  playthings.  Auscultation  in  these  mild  cases 
reveals  coarse  mucous  rales  in  the  larger  bronchial  tubes,  Avhile  the 
smaller  tubes  are  free  from  mucus.  SibiUmt  and  sonorous  rales  are  also 
observed,  especially  in  the  commencement  of  the  bronchitis,  at  which 
tim3  the  secretion  of  mucus  is  suppressed  or  scanty.  The  cough  in  the 
commencement  is  for  the  same  reason  dry.  It  becomes  looser  by  the 
second  or  third  day,  the  sputum  consisting  of  frothy  mucus,  with  the 
admixture  of  pus  and  epithelial  cells.  The  pus  becomes  more  abundant 
as  the  disease  continues.  Expectoration  from  the  mouth  does  not 
usually  occur  till  after  the  age  of  four  or  five  years ;  under  this  age  the 
sputum  is  ordinarily  swallowed. 

Tlie  mild  form  of  bronchitis  described  above,  that  in  which  only  the 
larger  bronchial  tubes  are  affected,  is  common  to  all  periods  of  infancy 
and  cliildliood,  but  a  severer  grade  of  the  disease  is  also  of  common 
occurrence,  exclusive  of  those  cases  in  which  the  minute  branches  of 
the  br()n(;hial  tree  are  affected.  It  has  already  been  stated  that  there 
is  a  tendency  in  bronchial  inflammation  to  extend  downward,  and 
symptoms  are  proportionate  in  gravity  to  the  degree  of  this  extension. 
In  severe  bronchitis  the  pulse  rises  to  120  or  130  per  minute,  and  the 
respiration  is  in  a  corresponding  degree  accelerated.  The  cough  is 
frcfjuent  and  ]iainfid,  the  pain  being  referred  to  the  sternum,  and  often 
there  is  a  steady  dull  ])ain  in  this  region.  Tlie  face  is  flushed  and  indi 
cative  of  suffering,  the  temperature  is  considerably  elevated,  and  the 
appetite  is  greatly  impaired  or  lost.     There  is  frecjuently  an  exa^erba- 


598  BRONCHITIS. 

tion  of  symptoms  in  the  latter  part  of  the  day.  Depression  of  the  infra- 
mammary  region  during  inspiration,  and  dihitation  of  the  ahB  nasi, 
accompany  grave  attacks  of  the  inllammation. 

Auscultation  in  severe  bronchitis  reveals  the  presence  of  rales  in  all 
parts  of  the  chest,  sibilant  and  sonorous  sparingly,  coarse  mucous  and 
subcrcpitant  more  abundantly. 

General  bronchitis  or  suffocative  catarrh,  the  most  dangerous  form  of 
this  inflammation,  is  less  frequent  than  bronchitis  ^vhich  is  limited  to 
the  larger  tubes,  or  to  the  larger  tubes  and  those  of  medium  size.  It 
may  commence  quite  abruptly,  but  ordinarily  it  results  from  the  milder 
form  of  the  disease.  The  symptoms  at  first  are  such  as  occur  in  the 
common  form  of  bronchial  inflammation,  but  instead  of  abatinfr  or 
remannng  stationary,  they  gradually  increase  in  severity  till,  suddenly, 
marked  dyspnoea  supervenes.  The  inflammation  has  now  reached  the 
minute  tubes,  and  what  promised  to  be  an  ordinary  attack  of  bronchitis 
becomes  one  of  great  severity  and  danger. 

The  respiration  in  severe  bronchitis  is  short  and  hurried.  Sixty  to 
eighty  inspirations  per  minute  are  not  infrequent,  -while  the  pulse  also 
is  greatly  accelerated,  attaining  as  high  a  number  as  140  to  IGO  or 
180  beats  per  minute.  The  cough  is  frequent,  and  the  sputum,  "which 
collects  in  abundance,  is  expectorated  with  difficulty.  If  expectorated 
so  as  to  be  examined,  it  is  found  to  consist  largely  of  frothy  mucus  with 
epithelial  cells.  After  a  few  days,  if  the  patient  live,  it  becomes  more 
purulent.  Sometimes,  as  in  bronchitis  of  the  adult,  streaks  of  blood 
appear  upon  the  mucus.  In  the  first  days  of  severe  acute  bronchitis, 
the  temperature  is  considerably  elevated,  the  face  flushed  and  breathing 
oppressed.  The  patient  is  restless,  moving  from  one  part  of  the  bed  to 
another,  seeking  in  vain  for  relief.  The  digestive  function  is  impaired, 
as  in  all  severe  inflammations  ;  the  tongue  is  moist  and  covered  with  a 
light  fur;  the  appetite  is  nearly  or  quite  lost.  The  infant  takes  the 
breast  Avith  diflSculty,  frequently  relinquishing  it  on  account  of  the 
dyspnoea;  older  cliildren  take  no  solid  food  in  consequence  of  the 
anorexia  and  the  dyspnoea,  and  even  drinks  are  swallowed  hastily  and 
apparently  without  relish,  since  deglutition  interferes  with  respiration. 
On  auscultation,  in  bronchitis  of  the  minute  tubes,  sibilant,  and  after  a 
day  or  two  subcrcpitant,  rales  are  observed  in  every  part  of  tiio  chest. 
Percussion  obtains  a  good  resonance,  unless  the  substance  of  the  lung 
have  become  involved.  As  the  disease  approaches  a  fatal  termination, 
the  pulse  becomes  greatly  accelerated,  tlie  respiration  is  also  in  a  corre- 
sponding degree  frequent  and  panting,  the  inspiration  being  accompa- 
nied by  marked  inframammary  depression  and  dihitation  of  the  aljc 
nasi.  The  face  becomes  pallid,  tlie  prolabia  livid,  and  the  tips  of  the 
finorers  livid  and  cool.  The  mucus  and  pus  accumulatins;  in  the  air- 
passages,  increase  more  and  more  the  obstruction  to  the  entrance  of  air, 
and,  finally,  death  occurs  from  apnoea.  The  nursing  infant  usually 
ceases  to  nurse  for  several  hours  before  death,  and  a  state  of  stupor 
commonly  precedes  the  fatal  event,  due  to  the  accumulation  of  carbonic 
acid  in  the  blood.  In  young  infants,  especially  those  under  the  age  of 
six  months,  not  only  in  bronchitis  of  the  minute  tubes,  but  in  severe 
ordinarv   bronchitis,  I   have  often  observed,  toward  the  close  of  life, 


DIAGNOSIS.  599 

intermission  in  the  respiration.  It  occurs  after  every  six  or  eight  or 
ten  respirations,  and  equals  in  duration  the  time  occupied  in.  perhaps, 
lialf  a  dozen  respiratory  movements.  It  is,  therefore,  an  unfavorable 
prognostic  sign,  but  some  in  whom  it  occurs  recover  by  stimulation. 

The  duration  of  acute  bronchitis  varies  according  to  the  extent  of  the 
inflammation.  In  the  mildest  form,  the  patient  is  convalescent  after 
three  or  four  days,  and,  in  severer  forms  that  terminate  favorably,  the 
disease  begins,  ordinarily,  to  decline  by  the  close  of  the  first  week  or  in 
the  second.  The  progress  of  bronchitis  is  somewhat  more  rapid  in 
voung  children  than  in  those  of  a  more  advanced  age.  When  conva- 
lescence is  fully  established,  it  is  not  unusual  for  the  cough  to  continue 
three  or  four  weeks,  though  gradually  declining.  It  is  loose  and  pain- 
less, and  is  scarcely  regarded  by  the  patient. 

Death  sometimes  occurs  as  early  iis  the  second  or  tliird  day  in  severe 
creneral  bronchitis.  The  younger  the  infant,  with  the  same  extent  and 
intensity  of  inflammation,  of  course  the  sooner  the  fiital  result.  The 
ordinary  duration  of  fiital  bronchitis  is  from  six  or  eight  days.  If  the 
patient  pass  beyond  the  tenth  day,  decline  of  the  inflammation  may  be 
confidently  expected,  and  recovery,  unless  there  be  a  complication. 

Occasionally  bronchitis  becomes  chronic,  lasting  several  months  before 
it  entirely  ceases.  The  chronic  form  may  result  from  mild,  as  well  as 
severe,  bronchitis.  The  acute  fever  and  accelerated  respiration  which 
cliaracterize  the  acute  affection  abate,  and  the  general  health  is  nearly 
or  quite  restored;  but  an  occasional  cough  continues,  and  the  respira- 
tion is  often  audible,  from  the  mucus  which  collects  in  the  tubes,  or 
from  thickening  of  the  raucous  membrane.  Sometimes  there  is  mod- 
erate febrile  movement,  especially  in  the  latter  part  of  the  day.  On 
auscultation,  coarse  raucous,  with  perhaps  sibilant  and  sonorous,  rales 
are  observed  in  the  chest. 

There  is  great  liability  in  chronic  bronchitis  to  exacerbations.  The 
disease  often  seems  to  be  abating,  and  there  is  prospect  of  its  speedy 
cure,  when  all  tlie  symjitoms  are  intensified.  The  exacerbations  are  due 
to  the  fict  that  the  bronchial  surface,  when  it  has  been  a  considerable 
time  inflamed,  is  very  sensitive  to  the  iin)>ression  of  cold.  Even  Avhcn 
the  disease  is  entirely  relieved,  it  is  very  liable  to  return  by  exposure  to 
currents  of  air  or  changes  of  temperature.  Chronic  bronchitis  occurs 
most  frequently  in  the  winter  and  in  the  spring  and  fiill,  when  the 
weather  is  changeable,  and  is  most  intractable  in  these  periods  of  the 
year.  Many  cases  of  chronic  bronchitis  are  associated  with  dilatation 
of  the  bronchial  tubes  or  with  emi)hysema.  The  general  health  in  this 
form  of  bronchitis,  when  not  dependent  on  a  tubercular  deposit,  ordi- 
narily remains  good.  Tubercular  bronchitis,  whicli  is  the  result  of  a 
grave  disease,  does  not  recjuire  separate  consideration.  It  is  attended 
with  emaciation,  and  is  obstinate  on  account  of  the  nature  of  the  primary 
afl'ectinn.  It  is  due  to  the  irritating  effect  of  tubercular  matter  lying 
against  the  bronchial  tubes. 

DiAOXCSis. — Bronchitis  can  ordinarily  be  diagnosticated  by  the  char- 
acter of  the  respiration  and  cough.  The  absence  of  hoarseness,  stridu- 
lous  inspiration,  and  croupy  cough,  excludes  laryngitis  ;  and  the  absence 
of  the  expiratory  moan  and  of  the  stitch-like  i)ain  on  coughing,  which 


600  BRONCHITIS. 

characterize  pneumonia  and  pleurisy,  excludes  those  diseases.  Accurate 
diagnosis,  however,  can  be  most  readily  made  by  percussion  and  auscul- 
tation. Examination  of  the  chest  enables  us  to  state  "with  positiveness, 
not  only  the  nature,  but  the  extent  of  the  affection.  If  the  inflamma- 
tion be  confined  to  the  larger  bronchial  tubes,  coarse  rjiles  are  discovered 
in  them,  while  finer  mucous  rales  are  absent.  If  the  bronchitis  be  in 
the  minute  tubes,  subcrepitant  riiles  are  discovered  in  them.  Percus- 
sion gives  clear  resonance  on  both  sides,  except  in  those  instances  in 
which  collapse  or  pneumonia  has  supervened. 

Prognosis. — IJronchitis  limited  to  the  larger  bronchial  tubes,  or  to 
these  and  those  of  medium  size,  terminates  favorably  in  a  large  majority 
of  cases.  Occasionally,  severe  inflammation,  not  extending  to  the  smaller 
tubes,  proves  fatal  in  young  infants,  or  those  of  feeble  constitution. 
Bronchitis  extending  to  the  minute  tubes,  is,  on  the  other  hand,  a  dis- 
ease of  great  danger.  It  may  be  fatal  at  any  period  of  childhood,  but 
the  younger  and  more  feeble  the  patient,  the  greater  the  liability  to  a 
fatal  result.  Under  the  age  of  one  year,  it  is  one  of  the  most  fatal 
diseases  of  early  life. 

The  prognosis,  in  the  commencement  of  all  cases  of  bronchitis  of 
average  severity  in  the  young  child,  should  be  guarded  on  account  of  the 
tendency  of  the  inflammation  to  extend,  as  has  been  already  stated  in 
the  preceding  pages.  After  five  or  six  days  extension  ceases,  and  if 
during  that  time  no  increase  in  the  severity  of  symptoms  occurs,  the 
prognosis  is  favorable.  Signs  which  indicate  an  unfavorable  result  are 
increasing  frequency  of  pulse  and  respiration,  difficult  and  scanty  ex- 
pectoration, restlessness,  a  countenance  expressive  of  suffering,  and  a 
progressively  greater  accumulation  of  mucus  in  the  bronchial  tubes,  as 
determined  by  auscultation.  Pallor  and  coldness  of  the  face  and  extrem- 
ities, lividity  of  the  tips  of  the  fingers,  rapid  and  feeble  pulse,  drowsi- 
ness, diminution  of  cough,  wdiile  the  mucus  and  pus  accumulate  in  the 
bronchial  tubes,  and,  in  young  children,  intermissions  in  the  respiration, 
indicate  the  near  approach  of  death.  Cases  uuiy,  however,  recover  by 
proper  treatment,  although  the  symptoms  are  most  unfavorable. 

It  is  unnecessarv  to  mention  the  favorable  prognostic  signs  of  bron- 
chitis. This  disease,  Avhen  fully  established,  continues  a  certain  number 
of  days,  whatever  remedial  measures  are  employed,  and,  if  the  symp- 
toms do  not  increase  in  severity  during  the  first  five  or  six  days,  a  favor- 
able result  is  highly  probable.  The  prognosis  in  chronic  bronchitis  is 
ordinarily  fixvorable,  so  far  as  life  is  concerned,  provided  that  no  ema- 
ciation occur.  If  there  be  emaciation,  the  bronchitis  may  be  due  to 
tubercles  in  the  bronchial  glands  or  lungs,  and,  of  course,  the  prognosis 
is  unfavorable. 

Treatment. — Bronchitis  may  be  rendered  much  milder,  and  perhaps 
prevented  by  an  emetic,  employed  in  the  first  twelve  or  twenty-four 
hours,  in  conjunction  with  a  warm  bath.  The  physician  is  not,  how- 
ever, oidinarily  called  sufficiently  early  to  render  this  treatment  effectual. 

Mild  Bronciiitis. — In  mihl  bronchitis  the  inflaunnation  is  limited 
to  the  larger  tubes,  or  to  tiiese,  aiul  those  of  medium  size.  Simple, 
soothing,  expectorant,  and  laxative  remedies  are  required  in  the  treat- 
ment of  this  form  of  the  disease.     Mild  counter-irritation  may  be  pro- 


TREATMENT,  GOl 

ducecl  by  camphorated  oil  or  the  occasional  ap})lication  of  a  As-eak  sina- 
pism, and  one  of  the  following  mixtures  may  be  given.  The  late  Dr. 
James  Jackson,  of  Boston,  in  his  letters  to  a  young  physician,  writes  of 
the  treatment:  "  For  young  children  I  employ  the  following:  Take  of 
either  almond  or  olive  oil,  of  syrup  of  squills,  of  any  agreeable  syrup, 
and  of  mucilage  of  gum  acacia,  equal  parts,  and  mix  them.  Of  this 
mixture  a  teaspoonful  may  be  given  to  a  child  at  two  years  of  age;  a 
little  less  if  younger,  and  increased  if  older,  so  as  to  double  the  dose  to 
one  in  the  sixth  year.  This  may  be  given  from  three  to  six  times  in 
the  twenty-four  liours.  Sometimes  a  little  opiate  must  be  added  at 
night  to  appease  the  urgent  cough."  Another  good  medicine  is  the 
mistura  glycyrrhizixj  composita,  half  a  teaspoonful  of  which  should  be 
given  every  two  hours  to  a  child  of  three  years,  and  one  teaspoonful  to 
one  of  six  years.  The  syrupus  ipecacuanhie  compositus  of  the  French 
pharmacopoeia,  the  contre  de  la  toux,  consisting  of  ipecacuanha,  senna, 
thyme,  poi)py,  sulphate  of  magnesia,  orange  flower  water,  Avine,  Avater, 
and  sugar,  being  soothing  and  slightly  laxative,  is  also  an  useful  remedy. 
These  cases  also  do  Avell  Avith  simple  mucilaginous  drinks  and  confinement 
in  a  Avarm  room. 

Bronchitis  affecting  the  Medium  Size  or  Smallest  Tubes. — 
The  use  of  leeches  has  been,  for  the  most  part,  abandoned  in  the  treat- 
ment of  bronchitis,  not  only  in  infancy,  but  at  all  ages.  The  applica- 
tion of  dry  cups  over  the  sternum  is  recommended  by  some  judicious 
physicians  as  a  i)roper  remedy  for  bronchitis  in  infancy  as  well  as  child- 
hood, and  the  use  of  the  Avet  cup  is  even  advocated  for  robust  infants  in 
the  commencement  of  the  inflammation;  but  the  beneficial  effects  of  its 
use  can  be  obtained  by  other  measures  Avhich  preserve  the  strength,  and 
are  therefore  preferalde. 

Local  treatment  a})plicd  to  the  chest  in  bronchitis  is  important,  since, 
if  properly  made,  it  increases  the  comfort,  and  obviously  diminishes  the 
intensity  of  the  inflammation.  Henoch,  Avhose  ample  experience  and 
sound  judgment  command  attention,  if  not  acceptance  of  his  vieAvs,  saj'^s 
of  local  treatment :  "  I  strongly  advise  hydropathic  applications  to  the 
chest  from  the  nock  to  the  umbilicus.  A  napkin  or  diaper  is  dipped  in 
Avater  at  the  temperature  of  the  room,  Avell  Avrung  out,  and  then  placed 
around  the  chest,  Avithout  exercising  any  compression,  so  that  the  arms 
are  free ;  this  is  surrounded  by  a  roll  of  batting,  and  then  covered  by  a 
layer  of  oil  silk  or  gutta-percha  paper.  When  the  fever  is  high  these 
applications  should  be  reneAved  at  least  every  half  hour ;  later  tlicy  may 
be  kept  for  one  or  even  two  hours,  aiul  this  continued  for  several  days 
and  nights.  I  have  occasionally  continued  it  for  a  Aveek,  the  cool  Avater 
being  changed  to  a  temperature  of  20°  to  27°  11." 

The  benefit  derived  from  the  cold  Avater  application  is,  according  to 
Henoch,  threefold:  first,  the  deep  inspiration  Avhich  the  application  of 
cold  causes,  thus  expanding  portions  of  the  lungs  Avhich  are  liable  to 
atelectasis;  secondly,  "derivative  irritation  of  the  skin;"  and,  thirdly, 
the  production  of  moisture  in  the  air  surrounding  the  child,  Avliich  he 
inhales.  Deep  inspirations  are,  in  my  oi)inion,  caused  to  a  greater 
extent  by  medicines  Avhich  excite  cough,  as  ammonia,  and  warm  appli- 
cations certainly  produce  more   derivation    to  the  surfiice  than  cold. 


602  BRONCHITIS, 

One  benefit  from  the  application  of  cold  Henoch  does  not  allude  to,  and 
that  is  the  reduction  of  temperature.  But  I  prefer  for  this  purpose 
frequent  sponging  of  the  upper  extremities  and  face  with  cold  water, 
and  perhaps  its  constant  application  to  the  head.  I  have  observed 
marked  relief  from  this  use  of  cold  water. 

For  years  in  my  practice  the  following  external  treatment  has  been 
employed  with  apparent  benefit  in  nearly  every  case.  Fur  infants 
under  the  age  of  three  months,  Avho  have  accelerated  respiration  and 
painful  cough  indicating  the  need  of  external  treatment,  two  poultices 
of  ground  flaxseed  are  prepared,  covered  by  thin  muslin,  and  made  so 
moist  that  they  wet  the  hand  in  holding  them.  They  are  made  as  thin 
as  the  pasteboard  cover  of  a  book,  and  of  such  a  size,  that  applied  in 
front  and  behind  they  cover  the  entire  chest.  Camphorated  oil  is 
smeared  over  their  under  surface  three  or  four  times  daily,  and  over 
their  exterior  oil  silk  is  applied.  For  infants  over  the  age  of  six  months 
I  prefer  poultices  of  the  following : 

R. — Pulv.  siuapis 5j. 


Pulv.  seiniiiis  lini 


5^^J- 


The  poultice,  to  give  most  relief,  should  be  so  wet  as  to  cause  constant 
moisture  of  the  surface,  and  so  irritating  as  to  cause  constant  redness, 
without  necessitating  its  removal.  Vesication  should  never  be  produced. 
Flannel  wrung  out  of  warm  water  made  slightly  irritating  by  mustard, 
and  covered  by  oil  silk,  also  answers  the  purpose.  External  treatment 
should  be  employed  in  most  instances  so  long  as  the  respiration  is  hur- 
ried and  cough  painful.  During  the  stage  of  convalescence,  instead  of 
the  poultice,  cotton  wadding  or  batting  around  the  chest  increases  the 
comfort  and  prevents  taking  cold.  Derivation  to  the  surface,  early 
made  and  continued,  tends  to  check  the  downward  extension  of  bron- 
chitis. Often  improvement  in  the  symptoms  is  observed,  especially  less 
dj^spnoea  and  restlessness,  immediately  on  the  employment  of  the  local 
measures  recommended  above. 

Internal  TreaTxMENT. — Medicines  are  indicated  which  have  a  ten- 
dency to  diminish  the  inflammation,  to  prevent  its  downward  extension 
to  the  minute  bronchial  tubes,  and  to  promote  expectoration.  The 
bowels  should  be  kept  open  in  all  cases  of  bronchitis.  For  robust  chil- 
dren, at  or  over  the  age  of  six  months,  the  following  prescription  is 
useful  in  the  commencement  of  the  attack  : 

R. — Syr.  ipecac, 

Spts.  iPtlier.  nitr afi  ^ij. 

01.  ricini giij. 

Syr.  bal.  tolut 5J. — Misce. 

Dose,  half  a  teaspoouful  to  one  teaspoonful,  every  second  hour,  for  the  age  of  one 
to  two  years. 

This  prescription  is,  I  think,  preferable  to  the  following,  recom- 
mended by  Henoch  : 

R._Hyd.  chlor.  mitis         ....  0.01-0.03  grains,  ]  to  f. 

Pulv.  rad.  ipecac 0.01       "       J. 

Sacch.  alb.  .        .  .         .  20.00 

To  be  given  every  two  hours. 


IXTERXAL    TREATMENT.  603 

But  the  medicinal  agent  which  experience  has  shown  to  be  the  most 
useful  in  the  bronchitis  of  children  is  one  of  the  salts  of  ammonium.  In 
the  treatment  of  infantile  bronchitis  depression  must  be  avoided.  The 
cough  should  be  strong  and  frequent,  for  the  chief  danger  occurs  from 
the  accumulation  of  viscid  mucus  in  the  minute  tubes  so  as  to  obstruct 
the  entrance  of  air  into  the  alveoli,  leading  to  atelectasis,  and  causing 
the  djspntjea  which  is  so  painful  and  prominent  a  symptom  in  this  dis- 
ease. Ammonium  carbonate  or  muriate,  better  than  any  other  agent, 
promotes  expectoration  by  exciting  cough,  and  rendering  the  mucus 
less  viscid,  and  it  does  not  reduce  the  strength.  When  anxious  parents 
ask  me  to  prescribe  something  to  relieve  the  cough,  I  reply  that  the 
more  frequent  the  cough  the  better  it  is  for  the  infont,  since  it  affords 
the  means  of  freeing  the  tubes  from  the  accumulating  mucus.  For- 
merly I  prescribed  largely  the  carbonate,  but  Dr.  Northrup,  Curator 
of  the  New  York  Foundling  Asylum,  has  found  evidences  of  gastritis  in 
the  stomachs  of  infants  who  have  perished  from  various  diseases,  for 
Avhich  the  carbonate  was  administered.  Since  informed  of  this  I  have 
prescribe<l  the  muriate.  Tlie  ammonium  muriate  may,  in  most  instances, 
be  given  Avith  benefit  from  the  commencement,  in  both  mild  and  severe 
bronchitis  in  infants  under  the  age  of  one  year.  The  following  is  a 
convenient  formula  for  its  employment : 

R. — Ammon.  muriat.    .......     z}. 

Syr.  bal.  tolut.         .......     gij. — Misce. 

The  ammonium  carbonate  should  be  pres(^ribed  dissolved  in  water, 
and  given  to  the  patient  in  milk. 

Fifteen  drops  contain  one  grain,  the  dose  at  the  age  of  tlireo  months. 
Five  drops  should  be  given  at  the  age  of  one  month,  and  thirty  at  the 
age  of  six  months,  in  a  little  water.  This  expectorant  should  be  given 
frequently,  as  every  half  hour  or  every  hour  in  cases  of  severity.  The 
urgent  symptoms  are  relieved  by  free  expectoration,  which  this  medi- 
cine more  tiian  all  others  which  I  have  em|)loyed  tends  to  produce.  It 
should  be  jriven  ni^jht  and  dav,  at  the  short  intervals  mentioned,  until 
amelioration  of  symptoms  occurs.  The  benefit  from  its  use  is  most 
apparent  under  the  age  of  eighteen  months,  or  at  the  age  when  capil- 
lary bronchitis  and  atelectasis  are  most  liable  to  occur. 

Medicines  Avhich  exert  a  greater  controlling  effect  on  the  action  of 
the  heart  than  those  which  we  have  mentioned,  are  often  re([uired  during 
the  progress  of  severe  "bronchitis."  If  tlie  patient  give  evidence  of 
declining  strength  while  the  pulse  is  unusually  rapid  and  the  temj)era- 
ture  elevated,  ([uinine  given  in  moderate  doses,  as  two  grains  every  fourth 
liour  to  a  child  of  two  years,  has  seemed  to  me  useful  as  a  heart  tonic. 
Tiie  tincture  of  digitalis  in  doses  of  one  to  two  drops  every  second  hour 
for  infants  between  tlie  ages  of  six  months  and  two  years,  is  also  useful 
as  a  heart  tonic.  In  a  case  recently  under  treatment  by  Dr.  Jacobi 
and  myself,  the  infant,  aged  twenty-three  months,  having  a  temperature 
varying  from  lU2i°  to  V^''>\°,  respiration  82  to  105,  and  pulse  l<i5  and 
higher,  took  four  drops  of  tincture  of  digitalis,  besides  the  quinine  and 
ammonium  muriate,  three  days   with  apparently  a  good  result  from  the 


604  BRONCHITIS. 

digitalis.      This  remedy  was  afterwards  continued  m  two-drop  doses, 
and  tlie  patient  recovered. 

For  robust  children  over  the  age  of  two  years,  in  the  commencement 
of  acute  bronchitis,  having  a  full  and  strong  pulse  and  flushed  cheeks,  a 
cardiac  sedative  is  required.  The  following  will  be  found  a  useful  recipe 
for  such  a  patient  at  the  age  of  five  years: 

K. — Tinct.  rad.  aconit ptt.  xvj. 

Syr.  scilliB  composit.       .         .         .         .         .         •     .^'J 

Syr.  bal.  tohit 5^''^'- — Misce. 

Dose,  one  teaspoonful  from  two  to  four  hours. 

The  medicine  should  be  omitted  or  given  at  longer  intervals,  if  the 
frequency  of  the  pulse  be  reduced.  Veratrum  viride,  on  account  of  its 
A'ery  depressing  action  is  not  so  safe  a  remedy  as  aconite.  In  children 
of  this  age  the  muriate  of  ammonium  is  also  required  as  an  expectorant; 
it  may  be  given  between  the  doses  of  the  above  mixture,  and  when  the 
latter  is  discontinued  it  shoidd  be  given  as  the  main  remedy. 

When  and  how  to  employ  opiates,  to  procure  the  needed  rest  in  the 
bronchitis  of  children,  should  be  carefully  considered.  We  have  stated, 
that  a  frequent  and  strong  cough  is  required  in  the  infant  in  order  to 
prevent  clogging  of  the  minute  tubes  with  muco-pus,  and  to  prevent 
atelectasis.  Still,  some  respite  from  tlie  cough  if  it  be  frequent,  is  re- 
quired to  prevent  exhaustion.  I  prefer  for  young  infents  to  give  the 
opiate  separately  from  the  expectorant,  and  only  occasionally,  as  they 
may  need  sleep.  The  following  is  a  useful  formula  for  an  infant  of  six 
months  who  is  restless  and  Avithout  the  proper  amount  of  sleep  : 

R. — Liq.  opii  composit.  (Squibb)  .....  gtt.  x. 

Potas.  bromidi         .         .         .         .         .         .         •  SJ- 

Syr.  rubi  idiei  (raspberry)       .         .         .         .         •  ^l- 

Aquie 5iss.— Misce. 

D'se,  one  teaspoonful  when  needed. 

Eight  drops  of  paregoric  may  be  given  in  place  of  the  above.  Twice 
the  dose  of  either  of  these  opiates  is  sufficient  at  the  age  of  twelve 
months.  For  older  children,  Dover's  powder — an  eligible  form  of 
which  is  Squibb's  liquid  Dover's  jiowder,  the  tinctura  ipecacuanlme 
composita — is  a  useful  remedy  to  procure  sleep,  one  minim  of  which 
corresponds  to  one  grain  of  the  powder. 

During  convalescence  medicines  should  be  administered  less  and  less 
frequently,  or  in  smaller  doses.  Emetics  in  ordinary  cases  of  bronchitis 
are  not  required,  except  in  the  commencement.  In  severe  bronchitis, 
hoAvevcr,  especially  when  the  smaller  tu])es  are  inflamed,  they  sometimes 
appear  to  1)C  useful.  The  cases  Avliich  may  need  their  adminstration  are 
those  in  which  mucus  and  pus  collect  in  the  tubes  more  rapidly  than 
they  are  expectorated,  so  as  to  give  rise  to  urgent  dyspnoea.  An  emetic 
administered  under  such  circumstances  may  give  prompt  and  decided 
relief.  The  object  to  be  gained  is  obviously  very  different  from  that  in 
the  commencement  of  bronchitis,  and  such  agents  should  be  employed 
as  act  promptly  with  little  depression.  Ipecacuanha  is  probahly  the 
best  emetic  for  this  purpose. 

Infants  oppressed  by  the  accumulation  of  mucus  and  pus  may  some- 
times be  relieved  by  tickling  the  fauces  with  the  finger.     This  provokes 


ATELECTASIS.  605 

vomiting,  and  the  viscid  mucus  which  collects  at  the  entrance  of  the 
flottis  is  removed  by  the  finger. 

The  diet  should,  as  a  rule,  be  nutritious  through  the  entire  disease ; 
but  robust  patients,  or  those  who  have  ordinary  health,  if  over  the  age 
of  two  years,  and  affected  with  primary  bronchitis,  are  sufficiently 
nourished  by  light  diet,  chiefly  farinaceous,  in  the  first  days  of  the 
attack,  after  which  animal  broths  are  proper.  Whatever  food  is  given 
in  S3vere  bronchitis  must  be  in  the  form  of  drinks,  since  the  appetite  is 
lost,  while  the  thirst  is  such  that  liquids  are  less  likely  to  be  refused. 

In  primary  bronchitis,  if  mild  or  of  ordinary  severity,  alcoholic  stimu- 
lants are  not  required.  In  secondary  bronchitis  they  are  often  needed, 
and  also  in  severe  primary  bronchitis,  if  there  be  dyspnoea  Avith  evidences 
of  prostration.  In  the  infant  two  drops  of  brandy  for  each  month  in 
the  age,  given  every  second  hour,  enable  the  child  to  expectorate  with 
more  freedom  and  less  exhaustion. 


CHAPTER  Y. 

ATELECTASIS.       ' 

Ix  certain  newborn  infimts  the  lungs  do  not  undergo  inflation,  or  only 
a  portion  of  the  lobules  is  inflated,  to  wit,  those  in  the  upper  lobes, 
while  the  remainder  of  the  organ  continues  unchanged  from  the  foetal 
state.  This  non-inflation  of  the  lung  is  designated  congenital  atelec- 
tasis. It  is  apparently  not  due,  unless  in  rare  instances,  to  defective 
formation  of  the  respiratory  apparatus,  for  at  the  autopsies  of  cases 
which  have  ended  fatally,  as  most  cases  do,  at  an  early  period,  insufilation 
is  easy,  there  being  no  occlusion  of  tlie  air-passages,  nor  unusual  adhe- 
sion of  the  walls  of  the  alveoli  to  prevent  the  admission  of  air.  Physi- 
cians have  believed  that  in  some  instances  they  discovered  the  cause  in 
an  enlarged  thymus  gland,  which  compressed  the  lower  part  of  the 
trachea,  but  this  cause  has  not  seemed  to  exist,  or  was  exceptional,  in 
cases  which  I  have  observed,  for  altbougli  the  thymus  at  birth  is  large, 
having  nearly  the  size  of  an  unexpanded  lung,  it  has  not  seemed  to  me 
to  be  unduly  enlarged  in  most  atelectatic  cases  which  I  have  examined 
after  death. 

The  ordinary  proximate  cause  of  atelectasis  neonatorum  is  feebleness 
of  inspiration,  whether  due  to  general  debility,  as  in  infants  born  per- 
maturely,  or  weakened  by  ))lacental  hemorrhage  in  the  last  months  of 
fnetal  life,  or,  as  is  frefpiently  the  case,  to  injury  of  the  brain  and  conse- 
quent impairment  of  the  function  of  the  pneumogastrics  during  birth. 
I  have  more  fully  treated  of  this  form  of  atelectasis  in  the  chapters  which 
relate  to  the  maladies  incidental  to  the  birth  of  the  chihl,  and  to  these 
the  reader  is  referred. 


60G  ATELECTASIS. 

Acquired  Atelectasis,  or  collapse  of  lung,  is  less  extensive  than 
congenital  atelectasis,  being  confined  to  a  portion  of  a  lobe,  and  often  to 
only  a  few  lobules.  It  occurs  chiefly  during  the  period  of  infancy  and 
in  feeble  children.  It  is  a  common  malady,  in  foundling  asylums,  in 
wasted  infants  who  perish  before  the  close  of  the  first  year.  I  have  fre- 
quently at  the  autopsies  of  such  infants  observed  it  along  the  thin  in- 
ferior margins  of  the  lower  lobes,  and  in  the  tongue-like  prolongation  of 
the  left  upper  lobe.  In  this  class  of  cases,  catai'rli  of  the  bronchial  tubes 
appears  to  have  little  or  no  agency  in  causing  the  collapse.  The  cause 
is  found  in  the  impaired  functional  activity  of  the  lungs.  In  the  state 
of  debility  the  heart  beats  feebly  and  the  stream  of  blood  from  it  to  the 
lungs  is  small  and  slow,  so  that  the  inspiration  of  a  small  amount  of  air 
suffices  for  its  decarbonization.  The  inspirations  also  are  seen  to  be 
feeble,  causing  little  expansion  of  the  walls  of  the  thorax.  Conse- 
quently the  entire  lung  is  imperfectly  inflated,  as  is  seen  in  fatal  cases, 
but  the  distant  thin  portions  of  the  organ  are  least  expanded.  These 
receiving  little  or  no  air,  soon  begin  to  contract  from  the  presence  of  the 
elastic  tissue,  and  collapse  or  atelectasis  ensues. 

Tliis  has  been  the  most  common  form  of  atelectasis  in  cases  of  this 
malady,  which  I  have  observed  in  foundling  asylums,  and  it  probably 
occurred  in  the  manner  which  I  have  described. 

Another  cause  of  acquired  atelectasis  to  which  all  Avriters  allude  is 
bronchial  catarrh,  which  commencing  in  the  larger  tubes  extends  down- 
ward into  those  of  smallest  size.  By  the  swelling  of  the  mucous  mem- 
brane, and  the  accumulation  of  viscid  muco-pus  which  cannot  be  expec- 
torated, certain  of  these  tubules  become  occluded,  so  that  the  inspired 
air  is  shut  off  from  the  alveoli  situated  beyond  them.  Occlusions  are 
obviously  most  likely  to  occur  in  the  bronchitis  of  feeble  infants,  whose 
cough  has  little  exj)ulsive  force,  so  that  debility  is  also  a  factor  in  the 
production  of  this  form  of  atele^-tasis.  The  portion  of  lung  withdrawn 
from  the  respiratory  function  soon  colla.])ses,  the  air  which  it  contained 
being  probably  in  part  expired,  but  chiefly  absorbed. 

Atelectasis  is  not,  however,  so  important  or  frequent  a  complication 
of  bronchitis  as  was  formerly  supposed,  for  catarrhal  pneumonitis  due  to 
extension  of  the  inflammation  from  the  bronchioles  into  the  lung  has 
been  mistaken  for  it.  Solid  non-crepitant  nodules  or  portions  of  lung 
are  frequently  observed  at  the  autopsies  of  infants  who  have  perished  of 
severe  bronchitis,  and  these  may  be  atelectatic  or  pneumonic,  but  they 
are  more  frequently  the  latter  than  was  formerly  supposed. 

The  possibility  of  insufflating  these  solid  portions  when  removed  from 
the  body  after  death,  was  till  within  a  few  years  regarded  as  decisive 
proof  of  atelectasis.  It  is  noAV  known  that  this  is  not  a  reliable  test, 
since  a  lung  solidified  by  recent  catarrhal  pneumonitis  can  be  almost  as 
readily  inflated  as  one  which  is  colhqjsed ;  but  the  inflated  pneumonic 
lung  is  more  solid  and  resisting  when  pressed  between  the  thumb  and 
fingers  than  is  the  collapsed  lung.  The  decisive  proof  is  afforded  by 
the  microscope,  by  which  cell-proliferation  is  discovered  within  the 
alveoli  in  catarrhal  pneumonitis,  while  it  is  lacking  in  simple  collapse. 
An  increase  of  the  dyspnoea  not  infrequently  occurs  in  severe  infantile 
bronchitis,  without  cither  pneumonia  or  collapse  from  the  accumulation 


ANATOMICAL    CHARACTERS.  GOT 

in  the  bronchioles  of  the  secretion  which  is  with  difficulty  expectorated, 
but  if  dulness  on  percussion  and  other  physical  signs  indicate  solidifica- 
tion of  the  lung  at  some  point,  of  course  pneumonia  or  collapse  has 
occurred.  If  a  sufficient  amount  of  lung  be  involved  to  produce  Avell- 
marked  physical  signs  the  disease  is  in  most  instances  pneumonia  and 
not  collapse,  though  it  may  be  the  latter.  Both  these  pathological  states 
may,  however,  occur  in  the  same  lung  as  complications  of  severe  bron- 
chitis. The  severe  paroxysmal  cough  of  pertussis,  especially  when 
accompanied  by  considerable  secretion,  frequently  produces  collapse  of 
portions  of  the  lower  lobes,  while  it  causes  emphysema  in  the  upper 
lobes. 

Symptoms. — Atelectasis  resulting  from  bronchitis  gives  rise  to  no 
new  symj)toms.  So  far  as  it  has  any  appreciable  effect  it  aggravates 
certain  symptoms  of  the  primary  disease,  but  as  it  is  ordinarily  limited 
to  a  small  area  this  effect  is  not  very  marked.  When  a  bronchial  tube 
is  so  occhided  by  muco-pus  that  the  alveoli  with  Avhich  it  communicates 
collapse,  there  is  ordinarily,  at  tlie  same  time,  more  or  less  accumulation 
of  this  secretion  in  other  tubes  throughout  the  lungs.  Therefore,  the 
entrance  of  air  into  the  alveoli  with  which  these  tubes  communicate  is 
slow  and  difficult,  but  usually  without  complete  obstruction,  and  with- 
out true  atelectasis,  but  with  a  semi-collapse  such  as  we  observe  in  fatal 
croup.  This  explains  the  dyspiiffia  which  is  present  in  these  cases.  If 
the  secretion  l)e  exj)ectorated  from  these  tubes  the  dyspnoea  abates,  even 
if  the  plug  which  has  completely  occluded  a  tube  and  the  consequent 
atelectasis  remain.  , 

Atelectasis  occurring  in  wasted  and  feeble  infants,  in  consequence  of 
the  diminished  force  of  the  inspirations,  does  not  in  most  instances  give 
rise  to  any  prominent  symptom,  since  it  occurs  chiefly  in  distant  thin 
portions  of  the  lungs.  I  have  observed  an  occasional  short,  nearly 
painless  cougli  in  such  infants,  when  the  autopsy  revealed  no  ])ulmonary 
lesion  except  the  atelectasis. 

Anatomical  Characters. — The  portion  of  lung  which  is  affected 
with  recent  atelectasis  has  a  dark  brown  or  dark  bluish  color.  It  is  de- 
pressed below  tlie  general  level  of  the  lung,  is  firm  and  non-crepitant  on 
pressure  and  its  inciseil  surface  is  smooth.  Ilypertx^mia  supervenes,  for 
a  portion  of  lung  in  which  the  circulation  continues,  but  from  which  air 
is  excluded,  becomes  congested.  In  acquired  atelectasis  the  congestion 
is  especially  marked,  since  the  vessels  which  have  been  adapted  by 
growth  for  a  larger  area  are  compressed  into  one  of  smaller  extent,  so 
that  they  become  tortuous  and  bulgi)ig  within  the  lumina  of  the  alveoli, 
while  the  free  iiow^  of  l)lood  through  them  is  retarded  by  the  constriction 
of  the  elastic  fit)res  of  the  lung.  An  o])vious  and  certain  result  of  the 
hypcrnemia  is  the  transudation  of  serum  into  the  alveoli,  producing 
oedema.  This  union  of  pulmonary  hyperpemia  Avith  oedema  by  which 
air  is  excluded  from  the  alveoli  constitutes  the  state  known  to  patholo- 
gists as  splenization,  and  in  proportion  as  it  occurs  the  lung  depressed 
by  the  atclcctiisis  rises  toward  the  general  level.  It  may  even  rise  above 
it,  and  it  now  has  a  doughy  clastic  feel.  The  pathology  of  these  (ede- 
matous atelectatic  spots,  heretofore  obscure,  has  been  clearly  explained 
by  Rindfleisch. 


608  ATELECTASIS. 

If  the  patient  live,  and  the  atelectatic  lobules  do  not  soon  letiirn  to 
a  state  of  health,  they  undergo  further  chiinges.  Kindfleisch  says: 
"From  the  serie;? '"  (of  changes,  provided  inllammation  do  not  occur) 
"  we  especially  render  prominent  two  conditions,  inveterate  oedema  and 
slaty  induration.  But  inflammation  does  commonly  occur  after  a  time 
in  a  collapsed  lung."  Those  who  are  familiar  with  the  post-mortem 
examinations  of  infants  will  fully  agree  with  Eindfleisch  when  he  says: 
"  Splenization,  quite  generally  taken,  appears  to  present  extraordinarily 
favorable  preliminary  conditions  for  the  occurrence  of  inflammatory 
changes.  It  may  directly  represent  the  initial  hyperemia  of  acute  in- 
flammation, and  be  followed  by  lobular  and  lobar,  but  constantly  catar- 
rhal infiltrates."  It  is  well  known  by  pathologists  that  protracted  con 
gestion,  active  or  passive,  of  whatever  organ  or  tissue,  is  very  liable  to 
pass  from  a  state  of  simple  stasis  of  blood  to  one  of  cell-proliferation, 
and  the  atelectatic  lung,  as  I  have  myself  observed  at  autopsies,  aff'ords 
a  common  example  of  this.  I  have  several  times  made  or  have  pro- 
cured microscopic  examinations  of  the  atelectatic  portions  of  lungs  of 
infants  who  had  died,  for  the  most  part,  in  a  wasted  and  enfeebled  state, 
and  have  found  in  them  clear  evidence  of  the  presence  of  a  catarrhal 
pneumonia.  The  interesting  fact  therefore  must  be  recognized,  that 
atelectasis  frequently  passes  to  a  state  of  inflammation,  so  as  to  present 
the  characters  of  ordinaiy  hypostatic  pneumonia,  and  no  doubt  undergo 
the  same  subsequent  changes. 

Atelectasis,  when  recent  and  simple  or  uncomplicated,  may  soon  dis- 
appear by  the  expectoration  of  tlie  obstructing  secretion,  if  such  be 
present,  or  if  there  be  no  obstruction,  by  increased  force  of  inspiration. 
If  it  do  not  soon  disappear  it  undergoes  one  of  the  ulterior  changes 
alluded  to  above,  and  henceforth  the  symptoms  and  history  are  those  of 
the  new  malady  which  has  supervened. 

Treatment. — The  treatment  of  acquired  atelectasis  is  simple.  If  it 
be  recent  and  there  be  evidence  that  it  is  due  to  the  accumulation  of  the 
secretion  in  the  bronchial  tubes,  an  emetic,  which  acts  promptly  and 
with  the  least  possible  depression,  may  be  very  useful.  It  is  especially 
indicated  if  there  be  little  or  no  pneumonia,  the  strength  not  greatly 
reduced,  and  there  be  dyspnoea  with  insuflficient  decarbonization  of  blood 
in  consequence  of  the  abundance  of  the  secretion  in  the  smaller  tubes. 
An  emetic  which  acts  promptly  and  with  little  prostration  may  aid 
greatly  in  establishing  the  respiratory  function  in  collapsed  lobules,  by 
expelling  the  obstruction,  and  producing  a  freer  and  deeper  inspiration. 
One  of  the  best  if  not  the  best  emetic  for  this  purpose  is  sulphate  of 
copper,  given  in  a  dose  of  one  or  two  grains  to  a  child  of  one  year. 
With  or  without  the  use  of  the  emetic  our  main  reliance  must  be  on  sus- 
taining and  stinndating  measures,  by  which  the  cough,  the  cry,  and  the 
inspirations  acquire  more  volume  and  force.  Most  cases  require  alco- 
holic stimulants  and  the  ammonium  carbonate.  Ilubefacient  applica- 
tions to  the  chest  are  also  commonly  employed,  and  are  probably  useful. 


p  X  E  u  M  0  N I  r  I  s .  609 


CHAPTER  YI. 

PXEUMOXITIS. 

Ix  children  over  the  age  of  three  years,  pneumonitis  differs  but  little 
in  form  or  phenomena  from  that  of  the  adult,  being  ordinarily  primary 
except  as  it  depends  on  an  irritant,  as  tubercles,  and  extending  rapidly 
over  one  or  more  entire  lobes.  It  is  the  form  of  pneumonia  which  is 
designated  lobar  or  croupous.  In  those  under  the  age  of  three  years 
pneumonia  is,  on  the  other  hand,  as  a  rule,  secondary  to  bronchitis.  It 
is  produced  by  extension  of  the  inflammation  from  the  bronchial  tubes 
into  the  alveoli,  and  it  affects  certain  lobules  instead  of  an  entire  lobe. 
It  is  designated  catarrhal  or  lobular  pneumonitis.  In  catarrhal  and 
croupmis  pneumonitis,  the  solidification  of  the  lung  and  exclusion  of 
air  are  due  mainly  to  the-  newly  formed  cellular  elements  with  which 
the  alveoli  are  filled,  though  these  cells  differ  in  the  two  diseases.  In- 
terstitial pneumonitis  consists  in  an  inflammation  and  hyperplasia  of  the 
connective  tissue  of  the  lungs.  It  is  the  chronic  pneumonia  of  authors, 
resembling  in  many  respects,  in  its  anatomical  and  clinical  characters, 
cirrhosis  of  the  liver.  The  inflammation  Avhich  produces  this  result  is 
subacute,  and  in  nearly  all  cases  is  dependent  on  some  persistent  local 
disease  in  the  minute  bronchial  tubes  or  lungs,  as  softened  or  cheesy 
tubercles,  cancer,  abscesses,  protracted  inflammation  of  the  alveoli  or 
bronchioles,  whether  produced  by  the  inhalation  of  dust  of  an  irritating 
natui*e  or  other  cause.  Interstitial  pneumonia  is  much  more  rare  in 
chihiren  than  adidts,  and,  as  it  presents  no  peculiar  features  in  them,  it 
need  only  be  alluded  to  in  this  connection. 

Causes. — Croupous  pneumonitis  in  most  cases  results  from  that  com- 
mon cause  of  inflammations — namely,  taking  cold.  It  commences  as  a 
primary  disease  within  a  few  liours  after  exposure.  Catarrhal  pneu- 
monitis, on  the  other  hand,  commonly  results  from  antecedent  patho- 
logical states,  which  we  will  enumerate. 

First.  Most  cases  of  capillary  bronchitis,  as  we  liave  stated  above,  result 
from  bronchitis.  The  inflammation  extending  downward  engages  the 
minute  bronchial  tubes,  and  from  them  traverses  the  alveoli  of  one  or 
more  lobules.  This  is  the  broncho-pneumonia  of  children  described  by 
authors;  it  occurs  most  frequently  between  the  ages  of  six  and  eighteen 
months. 

Secondly.  Ilypostisis,  or  passive  congestion,  is  an  important  factor 
in  the  causation  of  many  cases,  and  in  feeble  infimts  it  is  not  infre- 
quently the  sole  cause.  Infants  with  feeble  liealth  and  languid  circu- 
lation, lying  '\\\  their  crilis  day  after  day  with  little  movement  of  the 
))i>dy,  are  very  liable  to  passive  congestion  of  the  de])ending  portion-?  of 
their  lungs,  and  this  by  and  by  eventuates  in  a  cell-proliferation  within 
the  alveoli — in  other  words,  a  pneumonia  presenting  some  peculiarities, 

89 


610  PNEUMONITIS. 

but  of  the  catarrhal  form.  In  foundling  hospitals,  where  feeble  infants 
are  received  and  treated,  this  is  one  of  the  most  frequent  pathological 
states,  and  is  the  prevailing. form  of  pulmonary  inflammation.  It  is 
sometimes  described  as  hypostatic  pneumonia.  Hence  physicians  whose 
observations  have  been  largely  in  such  institutions,  have  almost  ignored 
any  other  form  of  pneumonia  in  infants.  Billard,  a  close  and  accurate 
observer,  wrote  nearly  half  a  century  ago:  "Pneumonia  of  infancy 
presents  peculiar  characters,  in  which  it  differs  from  the  same  affection 
in  adults.  Instead  of  being  an  idiopathic  affection  arising  from  irrita- 
tion developed  in  the  pulmonary  tissue  under  the  influence  of  atmos- 
pheric causes,  which  often  excite  the  disease,  the  pneumonia  of  young 
infants  is  evidently  the  result  of  a  stagnation  of  blood  in  their  lungs. 
Under  these  circumstances  this  blood  may  be  regarded  as  a  kind  of 
foreign  body It  would,  therefore,  appear  that  inflamma- 
tion of  the  lungs,  which  produces  hepatization,  arises  in  infants,  in  gen- 
eral, from  some  mechanical  or  physical  cause."  Valleix  also  states  that 
he  found  the  lesions  of  })neumonia  in  a  majority  of  the  infmts  who  died 
in  the  Hupital  des  Enfants  Trouves.  The  statements  of  Valleix  are 
applicable  also  to  the  Infants'  Hospital,  the  Foundling  Asylum,  and 
Nursery  and  Child's  Hospital,  of  this  city,  as  regards  those  cases  in 
which  death  results  from  chronic  disease.  We  shall  see  hereafter  that 
hypostatic  pneumonia  is  one  of  the  most  common  complications  of  chronic 
infantile  entero-colitis,  tlie  summer  complaint  of  the  cities. 

Thirdly.  Catarrhal  pneumonia  of  infants  sometimes  results  from  col- 
lapse. It  is  not  unusual  to  find,  at  the  autopsies  of  infants  who  have 
died  in  a  state  of  emaciation  and  feebleness,  portions  of  the  lungs  remote 
from  the  bronchi  collapsed,  as,  for  example,  the  thin  edges  of  the  inferior 
lobes,  and  the  tongue-like  process  of  the  upper  lobe,  the  process  Avhich 
lies  over  the  heart.  The  immediate  cause  of  the  collapse  has  been  a 
bronchitis,  or  it  has  resulted  directly  from  the  general  weakness  of  the 
infant,  and  its  feeble  respirations.  Now,  a  collapsed  lung  soon  becomes 
the  seat  of  passive  congestion.  The  functional  activity  of  an  organ 
favors  circulation  through  it,  and  if  the  function  be  abolished  the  flow 
of  blood  in  the  part  is  retarded,  and  stasis  more  or  less  complete  results. 
The  hvpera^mic  state  of  collapseil  pulmonary  lobules  presents  the  same 
anatomical  condition,  for  the  supervention  of  pneumonia,  as  occurs  in 
cases  of  hypostatic  congestion.  Consequently,  cell-proliferation  soon 
begins  in  the  collapsed  alveoli,  the  volume  of  the  affected  lung  in- 
creases, and  it  becomes  firmer  and  more  resisting  to  the  touch,  and  the 
microscope  reveals  the  characters  of  a  subacute  but  genuine  catarrhal 
pneumonitis.  I  have  made  or  have  procured  microscopic  examinations 
of  a  considerable  number  of  such  specimens,  and  have  found  the  alveoli 
more  or  less  filled  with  cells  of  the  epithelial  character.  (See  article 
Atelectasis.) 

In  rare  instances  in  infancy  and  childhood  pneumonitis  results,  as  it 
more  fre(|uently  does  in  the  adult,  from  an  embolus  detached  from  a 
clot,  which  had  formed  in  some  remote  vein,  in  consecpience  of  arrest 
of  circulation  in  it,  by  inflammation  of  the  contiguous  tissues.  This 
is  described  by  writers  as  a  distinct  form  of  pneumonitis,  designated 
embolic  or  embolismal.      A  specimen  showing  this  mode  of  causation 


AXATOMICAL    CHAEACTER3.  611 

■v«-as  exhibited  by  me  at  tlie  Xew  York  Pathological  Society,  in  Feb- 
ruary, 18G8.  An  infant,  born  January  22,  1868,  of  strumous  parents, 
nafi  been  fretful,  but  without  appreciable  ailment  till  February  3d,  when 
inflammation  of  the  connective  tissue  occurred  on  the  anterior  aspect  of 
the  left  leg,  a  little  below  the  knee. 
This    extended    downward,    suppurated,  ^°' 

and    the   pus    was    evacuated    February 
oth.     In  the  mean  time  three  other  sim- 

ihir  inflammations  occurred,  two  on  the  f-sss^    !'?«?■■¥   -k*- ^ 

right  foot  and  leg,  and  the  other  over  the  ^^  %C'>'  ?V*1  >^^  '^'* 

parietes  of  the  chest  in  the  rio;ht  infra-  %l  '%^'ii-t^  ^   \  ^  -^ 

mammary  region.     Suppuration  occurred  Afi'MM:  '  \  *i  i^C^W 

in  all  of  these.  '^  If'^M^  V^ '  -M^"^ 

On  February  8th  this  infiint  was  sud-  M^fwW:  ^"^^  / 
denly  seized  with  extreme  dyspnoea,  and  %1^  "^'^  '  'fe '*^V^^"^  f^" 
died  in  a  few  hours.     Numerous  minute  ^'       ^      ;t^'  -^ 

puriform  collections  (formerly  called  me- 
tastatic  abscesses)  were  discovered  in  each  lung,  most  of  them  scarcely 
larger  than  a  pin's  head.      One  of  them  on  the  right  side  in  the  middle 
lobe  connecting  with  a  bronchial  tube  had  ruptured  into  the   pleural 
cavity,  causing  pneumothorax,  collapse,  and  incipient  pleuritis. 

The  annexed  figure  exhibits  the  microscopic  appearance  of  this  soft- 
ened fibrin,  which,  to  the  naked  eye,  so  closely  resembled  pus. 

On  account  of  the  speedy  death,  the  embpli  had  produced  in  the 
lobules  where  they  had  lodged  little  more  than  congestion  or  the  first 
stage  of  pneumonitis  around  them-  Had  the  infant  lived  longer,  doubt- 
less the  ferments  or  the  vibriones,  which  some  consider  the  irritating 
element  of  emboli,  would  have  caused  a  greater  amount  and  more 
advanced  stage  of  pneumonia. 

Anatomical  Characters. — Xothing  need  be  added  in  this  connec- 
tion to  wiiat  has  already  been  said,  in  reference  to  interstitial  and  embo- 
lismal  pneumonias.  Being  comparatively  rare  in  children,  they  present 
the  same  anatomical  characters  as  in  the  adult.  That  unimportant  form 
of  pneumonia  called  pleurogenous,  and  which  consists  in  a  croupous 
inflammation  of  the  superficial  infundibuhi  of  the  lung  underneath  an 
inflamed  pleura,  occurs  in  cliildren  as  Avell  as  adults.  Being  secondary 
to  the  pleuritis,  and  produced  by  extension  of  the  inflammation  of  the 
pleura,  it  gives  rise  to  no  appreciable  symptoms,  on  account  of  its  slight 
extent,  and  as  it  presents  Ho  peculiar  features  in  the  child  it  need  only 
be  alluded  to. 

Croupous  pneumonitis,  which  we  have  stated  is  the  ordinary  form 
of  pulmonary  inflammation  in  children  over  the  age  of  five  years,  luis 
the  same  anatomical  characters  as  in  the  adult.  It  ordinarily  involves 
an  entire  lobe.  It  is  more  frequent  in  the  right  than  left  lung,  and  in 
whichever  lung  it  occurs  its  most  frequent  seat  is  the  lower  lobe.  The 
inflammation  may,  however,  be  limited  to  an  upper  lobe,  especially  on 
the  right  side.  It  ordinarily  commences  near  the  root  of  the  lung,  and 
extends  forward, 

Croupfnis  pneumonitis  presents  three  stages,  that  of  congestion,  red 
hepatization,  and  gray  hepatization.      In  the  stage  of  congestion  the 


012  PXEUMOXITIS. 

capillaries  in  the  walls  of  the  alveoli  are  greatly  distended,  hulging  for- 
Avard  in  loops  within  the  alveolar  spaces  so  as  to  diminish  them,  and  a 
viscid  albuminous  liuid  begins  to  exude,  in  wliich  points  of  extravasated 
blood  appear.  The  affected  lung  in  this  stage  has  a  deep  red  color,  its 
elasticity  is  greatly  diminished,  and  its  density  and  weight  increased. 
On  account  of  the  reduced  size  of  the  alveoli  from  the  bulging  of  the 
alveolar  walls,  and  the  viscid  fluid  within  the  alveoli  and  terminal  bron- 
chial tubes,  the  function  of  the  affected  lobe  is  nearly  lost,  and  hence 
the  dyspnoea  which  patients  experience  in  the  first  stage  of  the  inflam- 
mation. 

The  second  stage  is  characterized  by  the  continued  and  increased 
escape  of  the  lic[Uor  sanguinis  and  red  and  white  corpuscles  through  the 
stigmata  or  little  apertures  which  exist  normally  in  the  walls  of  the  capil- 
laries. The  inflamed  alveoli  and  the  minute  bronchial  tubes  which 
terminate  in  them  are  filled  with  this  pneumonic  exudation.  The  rela- 
tive proportion  of  the  elements  of  the  blood  in  the  exudate  varies  in 
diflferent  cases.  Fibrin  is  alwaj's  present,  immediately  coagulating  in 
delicate  filaments  Avithin  the  interstices  of  which  the  corpuscles  are 
lodged.  The  white  corpuscles  in  some  cases  are  much  in  excess  of  the 
red,  while  in  others  the  red  predominate.  The  lung  in  the  second  stage 
contains  no  air,  has  a  greater  specific  gravity  than  Avater,  is  friable  so  as 
to  be  readily  torn  and  penetrated  by  the  finger.  The  torn  surface  in 
the  adult  presents  a  granular  appearance,  each  granule  being  the  con- 
tents of  an  air-cell.  In  the  child  the  granules  are  not  distinct  on  ac- 
count of  the  small  size  of  the  air-cells,  but  the  volume  of  the  inflamed 
lobe  is  somcAvhat  increased  as  in  the  adult. 

The  stage  of  gray  hepatization  succeeds,  in  Avhich  the  volume  of  the 
lung  is  still  greater.  The  change  of  color  is  due  partly  to  compression 
of  the  capillaries  by  the  inflammatory  material,  partly  to  destruction  of 
the  red  corpuscles,  and  disappearance  to  a  greater  or  less  extent  of  their 
coloring  matter,  Avhile  the  white  corpuscles  (pus-cells)  remain,  but  it  is 
due  more  to  commencing  fatty  degeneration  in  the  exudate  prior  to  its 
licpiefaction.  In  favorable  cases  the  lung  soon  returns  to  its  normal 
state,  the  liquefied  substance  Avhich  filled  the  alveoli  being  in  part  ab- 
sorbed, ill  part  expectorated. 

Croupous  pneumonitis  often  causes  inflammation  of  the  portion  of  the 
pleura  Avhich  covers  it.  Pleuritis  developed  in  this  Avay  is  circum- 
scribed, but  it  frequently  extends  beyond  the  inflamed  parenchyma  to 
the  distance  of  one  or  tAvo  inches.  Bronchitis  is  also  a  common  accom- 
l^animent.  It  may  be  general,  in  Avhich  case  it  occurs  independently, 
or  be  limited  to  the  tubes  lying  Avithin  the  inflamed  lung,  in  Avhich  case 
it  results  like  the  pleuritis  from  the  pneumonitis.  It  is  seen  from  this 
description  that  the  pus-cells  Avhich  are  produced  so  abundantl^r  in  the 
alveoli  are  believed  to  be  chiefly  exuded  Avhite  corpuscles  of  the  blood. 
Possibly  some  of  them  may  be  produced  by  jiroliferation  of  the  epithelial 
cells  Avhich  line  the  alveoli,  in  the  same  manner  as  they  are  believed  to 
be  produced  in  the  bronchial  tubes. 

Catarrhal  pneumonitis,  Avhich  is,  as  Ave  have  stated,  for  the  most  part 
the  lobular  pneumonitis  of  Avriters,  and  Avhich,  with  an  occasional 
exception,  is  the  form  of  inflammation  in  children  under  the  age  of 


ANATOMICAL    CHARACTERS.  613 

three  years,  presents  not  only  clinical  but  anatomical  features,  which 
distinguish  it  from  the  croupous  form  of  the  disease.  Those  who  have 
witnessed  few  post-mortem  examinations  of  young  children,  and  Avhose 
views  of  the  lesion  are  influenced  by  the  expression  lobular,  suppose 
that  there  is  an  alternation  of  inflamed  and  healthy  lobules,  so  that  the 
sui'face  of  the  lung  presents  an  appearance  not  unlike  mosaic  work. 
This  is  a  mistake.  Although  an  entire  lobe  is  seldom  inflamed,  as  in 
croupous  pneumonitis,  the  inflammation  commonly  extends  over  more 
or  fewer  contiguous  lobules,  but  we  find  certain  lobules  in  the  midst 
of  the  inflamed  area  which  are  but  slightly  afiected  or  have  escaped 
entirely.  The  extent  of  the  inflammation  is  ordinarily  from  one  to  three 
inches,  but  I  have  seen  a  nodule  of  true  catarrhal  pneumonia  not  larger 
than  a  pea,  while  every  other  portion  of  the  lung  was  healthy.  On  the 
other  hand,  almost  an  entire  lobe  may  appear  hepatized  to  the  naked 
eye  as  in  the  croupous  inflammation,  but  by  a  careful  examination  cer- 
tain lobule^  will  be  found  unaftected.  Thus,  in  a  case  in  the  Nursery 
and  Childs  Hospital,  in  which  death  occurred  at  the  age  of  one  year 
from  pneumonitis  supervening  upon  pertussis,  an  entire  lobe,  with  the 
exception  of  a  little  of  its  anterior  border,  presented  the  appearance  and 
feel  of  red  hepatization-,  but  a  careful  microscopical  examination 
revealed  not  only  the  absence  of  fibrin  in  the  exudate,  showing  the 
catarrhal  nature  of  the  inflammation,  but  also  certain  lobules  in  the 
midst  of  the  inflamed  lung,  which  were  not  involved.  Prof.  Delafield, 
who  has  made  careful  microscopic  examinations  of  inflamed  lobules  in 
catarrhal  pneumonia  resulting  from  extension  of  the  inflammation  from 
the  bronchial  tubes,  says:  ''In  some  cases  the  air-vesicles  are  filled 
principally  with  pus;  in  other  cases  almost  entirely  with  epithelial 
cells;  in  other  cases  with  both  pus  and  epithelium  ;  in  others  with  pus, 
epithelium,  and  fibrin." 

Inflammation  of  tlie  pleura  over  the  inflamed  lung  is  less  frequent  in 
this  disease  than  in  croupous  pneumonia.  The  seat  of  catarrhal  jmeu- 
monia  is  ordinarily  the  posterior  part  of  the  lungs,  even  when  it  results 
from  extension  of  the  inflammation  from  the  bronchial  tubes.  When 
resulting  from  collapse,  it  aflects  chiefly  those  lobules  which  are  remote 
from  the  bronchi,  ami  which  the  air  enters  only  by  a  long  circuit. 

Catarrhal  pneumf>nitis,  when  it  arises  from  extension  of  acute  in- 
flammation of  th'j  bronchioles,  is  acute,  but  in  those  forms  of  the  disease 
which  supervene  upon  passive  congestion  it  is  subacute.  The  alveoli  are 
less  distended  by  inflammatory  products  than  in  croupous  pneumonia, 
not  only  from  the  less  amount  of  fibrinous  exudation,  but  also  of  cells. 
Hence  the  volume  of  the  inflamed  lung  is  not  so  great  as  in  that  disease, 
and  the  torn  surface,  even  in  the  adult,  does  not  present  so  <listinct  a 
granular  appearance.  Hence,  also,  the  stage  of  gray  hepatization  does 
not  supervene  so  uniformly  and  regularly,  since  there  is  less  compres- 
sion of  the  capillaries  in  the  alveolar  walls,  and  the  mutual  pressure  of 
the  inflammatory  products  is  less.  In  infants  who  have  died  with  this 
form  of  itneumonitis,  of  six  or  eight  weeks'  duration,  it  is  not  unusual 
to  find  the  affected  lobules  still  in  the  stage  of  red  hepatization.  Cell- 
proliferation  occurs  in  the  bronchioles  of  the  inflamed  lung  as  in  the 
alveoli,  producing  within  them  numerous  plugs,  which,  though  they  ob- 


014  PNEUMONITIS. 

struct  the  entrance  of  air.  are  not  so  firm  as  in  croupous  pneumonitis, 
since  they  contain  less  fibrin. 

In  favorable  cases  the  lung  afiected  by  catarrhal  infiammation  returns 
to  its  normal  state,  probably  by  the  same  process  as  in  croupous  pneu- 
monitis. In  other  cases,  especially  in  scrofulous  and  feeble  children, 
the  inflammation,  instead  of  resolving,  passes  into  what  is  now  desig- 
nated cheesy,  or  by  certain  writers  scrofulous,  pneumonitis.- 

Cheesy  Pneumonitis. — Cheesy  degeneration  of  the  inflammatory 
product  occasionally  occurs  in  the  croupous  form  of  inflammation,  but  it 
is  more  common  in  the  catarrhal.  I  have  most  frequently  observed  it 
in  New  York  during  epidemics  of  measles,  when  this  form  of  pneumo- 
nitis supervened  upon  the  catarrhal  bronchitis  of  that  disease.  Cheesy 
]>neumonitis  is  in  its  nature  chronic,  and  attended  with  great  reduction 
of  the  vital  powers. 

Cheesy  degeneration  of  the  exudate  or  infiltrate  consists  essentially 
in  the  absorption  of  the  liquid  portion,  and  fatty  degeneration  of  the 
solid.  The  obstruction  of  the  circulation  in  the  capillaries  and  the  ac- 
cumulation of  cells  in  the  alveoli  and  bronchioles  which  cannot  be  ex- 
pectorated, are  conditions  which  favor  cheesy  metamorphosis.  The 
appearance  and  consistence  of  the  lung  when  it  has  undergone  this 
change  are  Avell  expressed  by  the  term  which  is  employed  to  designate 
it.  The  cheesy  mass  consists  of  fatty,  shrivelled,  and  fragmentary 
cells,  and  amorphous  matter  in  which  can  be  traced  the  elastic  fibres 
and  larger  vessels  of  the  parenchyma,  the  other  histological  elements 
having  disappeared. 

The  caseous  mass  after  a  time  softens,  attracting  moisture  from  the 
suri'ounding  tissues.  The  molecular  detritus  and  the  shrivelled  cells  are 
now  suspended  in  a  liquid,  and,  like  any  dead  matter,  they  are  irritant 
to  the  surrounding  lung-substance.  The  bronchial  tube  which  supplies 
the  aifected  lobule,  and  which  in  many  instances  was  the  starting-point 
of  the  disease,  again  becomes  pervious,  either  by  softening  of  the  plug 
or  by  ulceration  at  a  higher  point  upon  its  walls,  and  air  is  adniitted, 
which  promotes  the  putrefactive  process  and  chemical  changes  of  the 
caseous  substance. 

The  lesion  now  described  is  that  of  pulmonary  consumption,  a  disease 
not  infrequent  in  children  of  two  or  three  years.  There  are  as  yet  no 
tubercles,  but  the  ])resence  of  softening  caseous  material  in  the  lungs 
very  fre(}uently  leads  to  their  development  (see  Art.  Tuberculosis),  and 
accordingly,  before  the  case  ends,  clusters  of  tu'jei'cles  may  ap|)ear  in 
the  connective  tissue  and  walls  of  the  vessels  of  the  lungs  and  in  other 
organs. 

In  the  subsequent  progress  of  cheesy  pneumonitis,  if  the  patient  live 
sufficiently  long,  more  or  less  expectoration  of  the  offending  substance 
occurs,  producing  a  cavity.  Around  the  cavity  a  vascular  pyogenic 
membrane  forms,  u])on  which  granulations  arise.  These  granulations, 
which  produce  pus  abundantly,  and  from  which  small  extravasations  of 
blood  are  frequent,  are  gradually  transformed  into  connective  tissue. 
If  the  dead  portion  be  expectorated,  and  there  be  a  single  small  cavity, 
the  child  may  recover,  the  empty  space  being  finally  filled  up  by  the  ex- 
tension of  the  granulations,  and  the  production  of  a  cicatrix,  which  con- 


SYMPTOMS,  615 

tracts,  producing  a  puckered  appearance.  Ordinarily,  however,  there 
are  several  centres  of  caseous  degeneration,  and  several  cavities  result- 
iuff,  which  continue  to  enlarge  by  the  progressive  softening  of  the  cheesy 
matter.  Often,  also,  certain  of  the  cavities  intercommunicate.  The 
bronchial  glands  undergo  hj^perplasia,  and  certain  of  them  are  liable,  also, 
to  become  cheesy.  As  the  disease  advances,  the  suppuration  and  ex- 
pectoration increase.  The  fatal  result  occurs  sooner  in  children  than 
in  adults,  and,  therefore,  the  destructive  and  inflammatory  lesions  ob- 
served at  autopsies  are  ordinarily  not  so  far  advanced  in  the  former  as 
in  the  latter.  Other  unfavorable  changes  may  occur  in  the  hepatized 
lung,  but  cheesy  degeneration  is  the  most  common  and  noteworthy. 

The  possibility  of  inflating  a  lung  which  presents  to  the  naked 
eve  the  appearance  of  pneumonitis,  has  long  been  regarded  as  a  reliable 
sign  of  tlie  pi-esence  or  absence  of  inflammatory  consolidation.  The 
facts  as  regards  the  possibility  of  insufflation  are  these:  In  croupous 
])neumonitis,  when  it  has  passed  beyond  the  first  stage,  insufflation  is 
impossible  in  the  lung  of  the  child  as  well  as  adult,  with  the  utmost 
force  of  the  breath.  Wc  produce  emphysema  in  healthy  portions  of  the 
lungs,  Avhile  the  inflame<l  area  is  not  encroached  upon. 

On  the  other  hand,  in  catarrhal  pneumonitis,  which  we  have  seen  is 
the  common  form  of  pulmonary  inflammation  in  children  under  the  age 
of  three  years,  and  in  which  less  distention  of  the  air-cells  by  inflam- 
matory products  occurs,  the  lung  can  be  inflated,  except  in  protracted 
cases,  but  when  fully  inflated  the  solidified  lobules  can  still  be  felt  be- 
tween the  thumb  and  fingers.  In  protracted  catarrhal  pneumonitis,  as 
well  as  in  protracted  collapse,  which,  indeed,  may  and  often  docs  become 
a  pneumonitis,  full  inflation  is  impossible.  Central  portions  still  remain 
impervious  to  air.  While,  therefore,  the  possibility  or  impossibility  of 
inflating  a  lung  removed  from  an  adidt,  and  which  presents  to  the  naked 
eye  the  appearance  of  pneumonic  solidification,  is  a  valuable  sign  as  in- 
dicating whether  or  not  the  disease  be  pneumonitis,  this  test  is  uncertain 
and  unreliable  when  applied  to  the  pulmonary  lesions  of  children  under 
the  age  of  three  years. 

Symptoms. — Croupous  pneumonitis  commonly  begins  abruptly,  or  it 
is  preceded  for  a  brief  period  by  symptoms  of  a  cold.  In  the  adult, 
the  abrupt  commencement  is  ordinarily  with  a  chill.  In  the  child,  there 
is  often  a  sensation  of  chilliness,  but  a  distinct  chill  is  not  common. 
Conv^ulsions  sometimes  occur  in  place  of  a  chill.  Catarrlial  pneumoni- 
tis, being  ordinarily  a  secondary  disease,  begins  in  a  more  gradual  way, 
its  .symj)toms  being  preceded  by  and  associated  with  those  of  the  prim- 
ary affection. 

Tlie  .symptoms  of  acute  pneumonitis,  wliether  catarrhal  or  croupous, 
arc  the  following:  Anorexia,  thirst,  restlessness,  elevation  of  tempera- 
ture, acceleration  of  pulse  according  to  the  intensity  of  the  inflammation 
and  the  feebleness  of  the  ])atient,  flushed  face,  a  countenance  expressive 
f)f  suffering,  accelerated  respiration,  with  an  expiratory  moan.  These 
.symj)toms  arc  constant  in  the  acute  inllamiuation  unless  of  the  mildest 
form.      Those  which  are  important  I  shall  explain  more  fully. 

Tiic  expiratory  moan  is  described  by  writers  as  a  pathognomonic 
symptom  of  this  disease,  or  of  pleurisy.     It  is  evidently  due  to  the  pain 


616  PNEUMONITIS. 

experienced  from  the  movement  of  tlie  inflamed  part.  As  a  rule,  the 
expiratory  moan  indicates  either  pneumonitis  or  simple  pleuritis  ;  but 
there  are  exceptions.  It  may  occur,  for  example,  from  indigestible  sub- 
stances in  the  stomach  and  intestines,  giving  rise  to  acute  dyspepsia; 
or  from  certain  forms  of  abdominal  inflammation,  which  render  move- 
ments of  the  diaphragm  painful,  as  diaphragmatic  peritonitis. 

Tiie  cough  in  the  first  days  of  pneumonitis  is  often  dry  or  hacking 
and  painful.  It  afterward,  if  the  case  be  favorable,  becomes  looser,  and 
is  jtainless.  AVe  very  seldom  observe  in  the  child  the  bloody  sputum 
which  cliaracterizes  pneumonitis  in  the  adult,  since  in  catarrhal  inflam- 
mation there  is  much  less  exudation  of  blood-corpuscles.  The  sjnitum, 
which  in  this  form  of  the  disease  is  the  product  of  secretion  and  cell- 
proliferation,  is  at  first  thin  and  frothy,  but  afterward  thicker  and  less 
tenacious  from  the  increased  number  of  cells.  There  is  often,  in  the 
first  period  of  the  inflammation,  pretty  severe  and  constant  headache, 
the  patient  complaining  of  the  head,  if  old  enough  to  speak,  before  he 
does  of  the  chest.  In  a  severe  attack  the  child  at  this  period  lies  with 
the  eyes  shut,  apparently  in  a  half-conscious  state,  fretful  if  spoken  to 
or  aroused,  so  that  the  physician  may  be  led  to  suspect  the  presence 
of  cerebral  disease.  If  there  be  vomiting,  accompanied  with  sudden 
twitching  of  the  muscles,  and  convulsions — symptoms  which  sometimes 
occur — the  liability  to  error  in  diagnosis  is  greatly  increased.  Cerebral 
symptoms  are  more  prominent  in  the  commencement  of  pneumonitis 
than  subsequently.  As  the  disease  advances  they  subside,  and  symp- 
toms referable  to  the  chest  become  more  conspicuous. 

The  breathing  is,  as  I  have  said,  accelerated.  Thirty  or  fort}^  respira- 
tions per  minute  are  common,  and,  in  severe  cases,  the  number  reaches 
sixty  or  even  eighty.  In  infants  there  is  greater  frequency  of  respira- 
tion than  in  children.  In  those  at  the  breast,  if  the  dyspnoea  be  urgent, 
nutrition  is  sometimes  seriously  interfered  with,  since  in  these  severe 
cases  respiration  is  performed  more  through  the  mouth  than  nostrils,  so 
that  if  the  infant  seize  the  nipple,  it  is  forced  to  relinquish  it  in  order  to 
breathe.  Dilatation  of  the  ahe  nasi,  and  depression  of  the  inframam- 
mary  region,  accompany  inspiration.  The  dyspnoea  in  catarrhal  pneu- 
monitis is  often  due  in  great  part  to  accompanying  bronchitis. 

The  temj^erature  in  mild  cases  of  pneumonitis  is  elevated  to  about 
101°  to  108°;  in  severe  cases  it  may  reach  105°  or  even  107°,  the 
former  being  the  higliest  observed  by  Mr.  S(juire.  In  ninety-seven  ob- 
servations made  l)y  M.  Roger,  the  average  temperature  was  1<.)4°  during 
the  active  period  of  the  inflammation.  The  face  is  therefore  flushed, 
and  the  heat  of  surface  pungent,  except  in  Aveakly  children,  in  whom. 
even  in  severe  and  active  inflammation,  the  face  is  sometimes  pallid,  and 
the  extremities- of  natural  or  less  than  natural  temperature. 

Tiie  tongue  is  moist,  and  covered  with  a  light  fur;  the  thirst  is  such 
that  nutriment  may  be  given  in  the  form  of  drinks,  when  the  loss  of 
appetite  prevents  the  use  of  solid  food.  Tlie  bowels  are  usually  consti- 
pated. The  secretions,  in  the  first  and  second  stages,  are  diminished. 
The  urine  is  more  deeply  colored  than  in  health,  and  in  vigorous  patients 
it  deposits  urates  on  cooling.  The  chlorides  are  also  deficient  or  absent 
from  the  urine,  so  long  as  the  inflammation  is  extending. 


PHYSICAL    SIGX3.  617 

In  favorable  cases,  in  from  seven  to  ten  days  the  heat  and  thirst  de- 
cline ;  the  pulse  and  respiration  gradually  become  less  frequent ;  the 
eoucrh  looser  ;  the  features  have  a  more  placid  or  contented  expression ; 
the  appetite  returns,  and  the  patient  is  again  amused  by  playthings. 
The  improvement  is  progressive,  but  gradual.  A  slight  cough  is  occa- 
sionally observed  two  or  three  weeks  after  convalescence  is  fully  estab- 
lished. 

Death  in  the  acute  stage  of  the  inflammation  commonly  occurs  from 
asthenia.  The  pulse  gradually  becomes  more  frequent  and  feeble,  the 
respiration  more  oppressed,  and  finally,  near  the  close  of  life,  the  face 
and  extremities  become  cool.  Occasionally  death  results  from  apnoea, 
due  in  great  part  to  coexisting  bronchitis.  In  exceptional  instances  it 
occurs  from  convulsions,  followed  by  coma,  especially  in  the  first  week. 
In  those  protracted  cases  in  which  the  inflammatoiy  products  have  un- 
dergone cheesy  degenei'ation  death  occurs  from  asthenia. 

Such  are  the  symptoms  and  progress  of  ordinary  acute  pneumonitis 
in  children.  When  the  inflammation  is  subacute,  as  in  those  forms  of 
the  disease  which  result  from  collapse  or  hypostasis,  the  symptoms  are 
less  pronounced.  The  respiration  in  such  cases  is  but  moderately  accel- 
erated, is  attended  by  little  pain,  and  therefore  the  expiratory  moan  is 
often  absent.  An  occasional  short,  dry  cough  occurs,  with  so  little  in- 
crease of  temperature  and  quickening  of  the  pulse  that  the  pneumonitis 
is  often  overlooked  by  tlie  physician,  the  symptoms  being  referred  to 
bronchitis.  Pleuritis  seldom  occurs  in  connection  with  this  form  of 
pneumonitis,  except  when  a  small  abscess  or  gangrene  results  in  an  af- 
fected lobule  directly  under  the  pleura.    A  few  such  cases  I  have  observed. 

Tubercular  pneumonitis  extends  over  much  or  little  of  the  lung  accord- 
ing to  the  amount  of  tubercles.  The  symptoms  are  like  those  of  severe 
primary  pneumonitis,  superadded  lo  such  as  pertain  to  tuberculosis. 
This  inflammation,  when  once  established  in  the  consumptive  child, 
commonlv  continues  till  the  close  of  life.  I  have  sometimes  had  these 
cases  under  observation  for  several  consecutive  weeks,  even  months,  and 
during  the  whole  time  there  was  not  only  acceleration  of  pulse  ancl 
respiration,  but  the  expiratory  moan.  As  regards  pneumonitis  occur- 
ring in  hooping-cough,  it  is  an  interesting  fact  that  its  symptoms 
modify  those  of  tiie  primary  disease,  so  that,  during  the  active  period 
of  the  inflammation,  the  paroxysmal  cough  diminishes,  and  a  short, 
hacking  cough  and  expiratory  moan  occur  in  place.  As  the  inflamma- 
tion abates,  the  spasmodic  cough  returns.  Pneumonitis  occurring  in 
measles  is  more  obstinate,  protracted,  and  dangerous  than  the  primary 
form.  It  usually  commences  about  the  period  of  the  decline  of  the 
eruption,  and,  in  favorable  cases,  continues  two  or  three  weeks.  It  is 
then  a  sequel,  rather  than  complication. 

Physical  Skins. — The  pliysical  signs  of  pneumonitis  in  infancy  and 
childhood  are  the  same  as  in  the  adult,  but  in  a  large  proportion  of 
cases  they  are  less  distinct.  In  a  majority  of  patients  under  the  age 
of  three  years  the  crepitant  rfde  is  not  observed.  This  is  due  to  the 
small  size  of  the  alveoli  at  this  age.  I  have  now  and  then  detected  it 
in  quite  young  children,  in  whom  it  is  a  finer  rale  than  in  the  adult. 
If  observed,  it  is  positive  proof  of  the  existence  of  pneumonitis.     The 


618  PNEUMONITIS. 

physical  signs,  therefore,  in  the  first  stage  of  the  inflammation,  are  often 
obscure  in  consequence  of  the  absence  of  the  pathognomonic  rale.  The 
vesicukir  murmur  is  somewhat  intensified  through  the  cliest,  and  there 
is  at  this  stage  slight  dulness  on  percussion  over  the  seat  of  the  inflam- 
mation due  to  engorgement  of  the  vessels,  but  it  is  difficult  to  appreciate 
this. 

In  the  second  stage,  Avliich  supervenes  more  or  less  rapidly,  the 
physical  signs  are  more  distinct.  Bronchial  respiration  is  in  most 
cases  detected,  higher  in  pitch  than  the  vesicular  murmur,  with  the 
sound  of  expiration  higher  than  that  of  inspiration.  The  voice  of  the 
patient  is  transmitted  to  the  ear  applied  over  the  seat  of  the  disease, 
and  often  a  peculiar  vibratory  sensation  is  communicated  to  the  hand 
applied  over  the  part,  so  that  it  is  possible  to  locate  the  disease  by  pal- 
pation alone.  In  the  second  stage,  an<l  sometimes  in  the  first,  coarse 
mucous  rales  in  various  parts  of  the  chest  are  often  observed  occurring 
from  coexisting  bronchitis. 

Percussion,  in  the  second  stage,  elicits  a  dull  sound  as  compared 
with  that  produced  on  the  opposite  side  of  the  chest.  The  dulness 
corresponds  in  extent  with  the  solidification,  and  with  the  bronchial 
respiration. 

As  the  inflammation  abates,  the  dulness  on  percussion  gradually 
diminishes,  and  the  bronchial  respiration  is  succeeded  by  the  subcrepi- 
tant  rale.  Often,  for  a  considerable  period  after  convalescence  is 
established,  moist  rales  are  observed  in  the  chest,  and  sometimes  the 
dulness  on  percussion  does  not  entirely  disappear  until  the  health  is  fully 
restored. 

In  catarrhal  pneumonitis  these  signs  are  commonly  less  distinct  than 
in  the  croupous  form  of  inflammation.  This  is  due  in  part  to  the  lim- 
ited extent  of  -the  inflammation,  in  part,  in  many  cases,  to  its  subacute 
character,  and  in  part  to  t\\e  fact  that  it  is  in  many  patients  double,  so 
that  we  lose  the  aid  of  comparison.  When  it  results  from  hypostatic 
congestion  it  is  nearly  always  bilateral. 

Diagnosis. — It  will  aid  in  diagnosis  to  recollect  that  under  the  age 
of  three  years  pneumonitis  is  ordinarily  catarrhal,  and  that  it  is  pre- 
ceded by  and  associated  with  bronchitis.  Coincident  with,  and  often 
preceding  its  development  for  a  few  days,  are  the  usual  symptoms  of 
nasal  and  bronchial  catarrh.  Defluxion  from  the  nostrils,  and  other 
symptoms  due  to  "taking  cold,"  help  us  to  diagnosticate  catarrhal 
pneumonitis  from  the  essential  fevers,  with  the  exception  of  measles. 
Croupous  pneumonitis  begins  more  abruptly,  but  in  this  form  of  inflam- 
mation the  greater  extentof  pulmonary  solidification  soon  gives  us  clear 
and  unmistakable  physical  signs.  The  various  forms  of  so-called  remit- 
tent fever  bear  considerable  resemblance  as  regards  symptoms  to  certain 
cases  of  pneumonic  inflammation,  but  in  the  latter  there  are  more  accel- 
eration of  respiration  and  greater  suff'cring,  especially  when  the  child 
is  disturbed,  than  in  the  former.  The  physical  signs,  liowever,  afford 
decisive  proof  of  the  nature  of  the  malady,  as  dulness  on  percussion, 
bronchial  respiration  of  a  higher  pitch  and  harsher  than  the  normal 
vesicular  respiratory  sound,  bronchophony,  vocal  fremitus,  etc. 

Difficulty  sometimes  attends  the  diagnosis  of  bronclio-pneumonitis 


PROGNOSIS.  619 

from  simple  bronchitis.  The  presence  of  the  expiratory  moan,  if  it  be 
pretty  constant  and  marked,  affords  evidence  that  the  inflammation  has 
extended  to  the  lungs,  but  the  physical  signs  constitute  the  reliable 
means  of  exact  diagnosis.  They  should  be  carefully  noted,  in  order  to 
determine  if  there  be  some  point  of  solidification. 

Solidification  gives  rise  to  dulness  on  percussion,  bronchial  respira- 
tion, and  bronchophony.  These  three  signs  coexisting  afford  suf- 
ficient proof  of  pneumonitis,  unless  there  be  tubercular  consolidation  or 
possibly  collapse  supervening  on  suffocative  bronchitis.  The  history  of 
the  case  aids  in  determining  whether  there  be  either  of  these  diseases. 
Moreover,  collapse  occurs  later  after  the  attack  commences  than  hepa- 
tization, and  does  not  produce  so  distinct  bronchophony  or  bronchial 
respiration  as  is  observed  in  ordinary  cases  of  pneumonitis. 

Pleuritis  -with  effusion  may  present  physical  signs  -which  bear  con- 
siderable resemblance  to  those  in  pneumonia;  but  in  pneumonia, 
except  when  associated  with  tubercular  disease,  the  dulness  on  percus- 
sion is  not  so  great  as  that  from  pleuritic  effusion.  In  pleuritic  effu- 
sion in  a  young  child  the  respiratory  murmur  can  often  be  heard  with 
the  ear  applied  over  the  liquid,  but  it  is  indistinct  and  transmitted 
through  the  liquid  from  a  distance.  The  practised  ear  is  able  to  dis- 
cover the  difference  between  it  and  the  bronchial  respiration  of  pneumo- 
nitis. Vocal  fremitus,  which  is  absent  in  pleuritic  effusions,  is  another 
reliable  sign  of  pneumonitis  in  children  over  the  age  of  three  or  four 
years.  In  younger  children  it  is  indistinct.  Occasionally  the  physical 
sic^ns  indicate  the  coexistence  of  the  pulmoilary  and  pleural  inflam- 
mations. 

In  catarrhal  pneumonitis  it  is  oftsn  difiicult  to  determine  certainly  the 
nature  of  tlie  disease,  since  the  physical  signs,  if  there  be  but  little  ex- 
tent of  inflammation,  are  absent  or  indistinct.  I  have  often,  in  post- 
mortem examinations,  found  so  small  a  part  of  the  lung  hepatized  that 
it  could  not  p<jssibly  have  produced  any  appreciable  dulness  on  percus- 
sion, bronchial  respiration,  or  bronchophony.  Such  cases  often  pass  for 
simple  bronchitis,  and,  practically,  this  matters  little,  since  the  treatment 
required  by  the  two  is  not  dissimilar. 

PuoGXOSls. — Primary  pneumonitis,  affecting  only  one  lung,  if  pro- 
perly treated,  in  most  instances  terminates  favorably  in  children,  and 
even  in  infants.  If  double,  it  is,  as  in  the  adult,  much  more  serious, 
and  in  a  large  proportion  of  cases  fatal.  Secondary  pneumonitis,  pneu- 
monitis occurring  in  measles,  hooping-cough,  tuberculosis,  or  resulting 
from  hypostatic  congestion  in  the  course  of  some  exhausting  disease,  is, 
on  the  other  hand,  more  frequently  fatal.  As  death  usually  occurs  from 
asthenia,  the  younger  the  child  and  more  feeble  the  constitution,  the 
greater  the  danger. 

Unfavorable  symptoms  are  a  pulse  becoming  more  and  more  fre([uent 
and  feeble,  })allor  of  countenance,  inability  of  the  patient  to  support  the 
head,  total  loss  of  appetite,  refusal  to  notice  or  be  amused  by  ]day- 
things,  absence  of  tears  when  crying — a  symptom  which  French  writers 
have  pointed  out — and  the  appearance  of  pemphigus  on  the  face  or 
elsewhere. 


620  PNEUMONITIS. 

Indications  on  which  a  favorable  prognosis  may  be  based  are  mod- 
erate acceleration  of  pulse,  pneumonitis  primary  and  limited  to  one 
Bide,  ability  to  support  the  head  or  sit  erect,  being  amused  by  play- 
things, etc. 

Treatment. — The  treatment  of  the  two  forms  of  pneumonitis,  namely, 
catarrhal  and  croupous,  the  former  occurring  chietly  under  the  age  of 
three  years,  and  being  secondary,  the  latter  occurring  in  most  patients 
over  that  age,  requires  to  be  considered  separately  as  much  as  do  their 
symptoms  and  anatomical  characters. 

Catarrhal  pneumonitis  when  developed  from  and  upon  a  bronchitis, 
as  it  so  often  is,  re(i[uires  for  the  most  jnirt  the  continuance  of  the  reme- 
dies which  are  appropriate  for  the  primary  disease.  (See  Art.  Bron- 
chitis.) But  from  the  fact  that  it  is  secondary,  and  in  children  of 
tender  age,  and  since  the  danger  as  regards  the  pneumonitis  is  due  to 
asthenia,  more  actively  sustaining  measures  are  demanded  than  are 
required  for  uncomplicated  bronchitis.  When  the  pneumonitis  has 
continued  a  few  days,  and  often  in  its  commencement,  carbonate  of  am- 
monium and  alcoholic  stimulants  are  needed,  and  the  diet  from  the  first 
should  be  nutritious.  An  opiate,  as  the  compound  tincture  of  ipecacu- 
anha, should  be  added  to  the  cough-mixture,  if  there  be  restlessness  or 
insufficient  sleep,  and  the  external  treatment  recommended  for  bronchitis 
should  be  continued.  In  that  form  of  catarrhal  pneumonitis  which  is 
due  to  passive  congestion  or  hypostasis,  in  the  causation  of  Avhich  debility 
is  an  important  factor,  tonic  and  stimulating  measures  are  still  more 
imperatively  required.  Frequent  change  of  position  is  useful  in  such 
cases. 

In  croupous  pneumonitis,  if  seen  at  the  commencement  or  within  a 
few  hours  of  the  commencement,  an  emetic  of  ipecacuanha  may  be  given, 
as  recommended  by  Trousseau.  This  acts  promptly  as  a  cardiac  seda- 
tive, diminishing  somewhat  the  afflux  of  blood  to  the  lungs,  and  moderat- 
ing the  inflammation.  It  should  not  be  employed  except  at  the  period 
mentioned. 

The  abstraction  of  blood  by  leeches  or  otherwise  has  justly  fallen  into 
disrepute  in  the  treatment  of  the  inllananations  of  children,  since  it  is  too 
depressing.  But  while  the  application  of  leeches  in  catarrhal  pneumo- 
nitis is  very  rarely  admissible,  on  account  of  the  tender  age  of  the 
patient  and  the  secondary,  character  of  the  inflammation,  they  nuiy  be 
useful  in  robust  children  with  croupous  pneumonitis,  if  applied  suffi- 
ciently early,  namely,  Avithin  the  first  twelve  hours.  Two  leeches  are 
sufficient  for  a  child  of  five  years.  When  solidification  of  the  lung  has 
occurred,  the  time  for  the  abstraction  of  blood  is  past.  But  we  have  in 
aconite  and  veratrum  viride  efficient  substitutes  for  bloodletting,  which, 
by  their  sedative  effect  on  the  heart,  diminish  the  exaggerated  afflux  of 
blood  to  the  inflamed  lung,  and  thus  enable  us  to  meet  the  indication 
of  treatment  in  the  first  stage  of  the  inflammation.  It  is  important  in  all 
severe  cases  to  preserve  the  blood  and  the  strength,  for  the  danger  in 
the  end  is  chiefly  from  asthenia.  Aconite  as  a  cardiac  sedative  in  the 
treatment  of  children  is  safer  than  veratrum  viride;  it  is  not  necessary 
to  watch  its  effects  so  carefully. 


T  R  E  A  T  M  E  X  T  ,  621 

The  following  will  be  found  a  useful  formula  for  a  child  of  five  years 
in  the  commencement  of  pneumonia  : 

R. — Tine,  ipecac,  comp.  (Squibb's)  .....     gtt.  xxxij. 

TiiicC.  rud.  aconit.      .......     gtt.  xvj. 

Syr.  bal.  tolut. 

Aquse •     aa5J. 

Dose,  one  tea?poonfiil  every  three  hours;  or  the  aconite  maybe  given  alone, 
dropped  in  sweetened  water  or  syrup  of  tolu. 

If  broncliial  respiration,  bronchophony,  and  dulness  on  percussion  are 
present,  indicating  the  second  stage;  in  other  words^  if  it  appear  from 
the  signs  that  the  inflamed  lobe  or  lobes  are  hepatized,  little  benefit 
accrues  from  the  further  use  of  aconite  or  veratrum  viride,  and  harm 
may  result.  In  this  stage  the  above  prescription,  with  the  aconite 
omitted,  may  be  continued,  or  the  following  may  be  employed: 

R  — Morph.  sulphat.  ......     gr.  j. 

S\-r.  ipecacuanhoe        .         .         .         .         .         .      5ss. 

Syr.  bal.  tolut.  .......      ^5  iijss. — Misce. 

Dose,  one  teaspoonfiil  every  three  hours  to  a  child  ot'  five  years. 

The  remarks  made  in  reference  to  the  use  of  quinia  and  digitalis  for 
bronciiitis  apply  Avith  still  more  force  to  their  use  in  both  the  catarrhal 
and  croupous  fuims  of  pneumonitis.  In  secondary  pneumonitis  and  in 
primary  occun-ing  in  feeble  children  these  agents  are  in  many  instances 
preferable  to  any  other  medicine  for  the  purpose  of  reducing  the  tem- 
perature and  pulse,  since  they  produce  this  result  without  depression. 
They  may  be  aihninistered  in  such  cases  from  the  first  day,  and  their 
use  may  obviously  be  continued  longer  than  wduld  be  safe  for  aconite  or 
veratriiiu  viride. 

From  some  observations  recently  made  (IS8O-I881)  in  the  New  York 
Foundling  Asylum,  it  seemed  to  us  probable  that  quinine,  given  in  one 
or  two  large  doses  at  the  commencement  of  acute  primary  pneumonitis, 
as  five  grains  to  a  child  of  three  years,  exerts  some  controlling  effect 
on  the  inllammation,  perhaps  even  rendering  it  abortive,  and  that  its 
subse({uent  use  in  smaller  doses  may  yet  sui)ersede  in  great  part  that  of 
aconite  and  veratruin  viride. 

When  the  inflammation  begins  to  abate  there  is  usually  progressive  im- 
provement. Many  now  recover  with  simple  mucilaginous  drinks  or  mild 
expectorants  useful  for  the  accompanying  bronchitis,  as  syrup  of  ipecac- 
uanha or  squills  in  small  doses.  Others  require  more  sustaining  meas- 
ures, and  f  jr  such  carbonate  of  annnonium  is  preferable  witli,  ])erhaps, 
(juinia.  In  severe  pneumonitis  it  is  of  tlie  utmost  inq)ortance  to  sustain 
the  vital  powers,  even  from  the  commencement  of  the  inflammation. 
There  can  be  no  doubt  that  the  great  error  in  the  therapeutic  manage- 
ment of  children  with  this  malady  has  1)een  the  employment  of  medicines 
which  reduce  tlie  strength  when  gentler  measures  or  those  of  a  sustain- 
ing nature  were  needed.  Alcoholic  stimulants  are  recpiired  sooner  or 
later  in  most  cases,  at  an  early  period  in  feeble  children  and  in  secondary 
form.s  of  the  inflammation.  Infants  may  take  three  or  four  drops  of 
Bourbon  whiskey  or  brandy  for  each  month  of  their  age  every  two  or 
three  hours.  The  diet  should  bo  nutritious,  consisting  of  milk,  animal 
broths,  and  the  like,  unless  during  the  first  three  or  four  days  in  robust 
children. 


622  PLEURITIS. 

The  bowels  should  be  kept  open,  as  an  miportant  part  of  the  treat- 
ment of  croupous  pneumonitis  in  its  first  stages.  A  small  dose  of  castor 
oil,  Rochelle  salts,  or  citrate  of  magnesium  should  be  given  if  there  be 
any  tendency  to  constipation,  and  repeated  from  time  to  time  if  re- 
quired. A  saline  aperient  by  its  derivative  and  refrigerant  effect  in 
some  cases  obviates  the  necessity  of  employing  cardiac  sedatives.  A 
laxative  enema  is  preferable  fur  a  feeble  child,  and  in  most  cases  of  sec- 
ondary pneumonitis. 

Local  treatment  is  required  in  all  cases ;  counter-irritation  should  be 
produced  as  soon  as  possible  over  the  inflamed  lobe,  by  mustard,  iodine, 
or  some  stimulating  liniment,  and,  except  at  the  time  of  this  a])plication, 
the  chest  should  be  constantly  covered  with  an  emollient  poidtice,  or 
with  a  cloth  wrung  out  of  warm  water  and  covered  W'ith  oil-silk.  I 
prefer,  however,  the  constant  application,  under  the  oil-silk,  of  the  fol- 
lowing poultice,  made  large,  but  as  thin  as  the  pasteboard  cover  of  a 
book,  and  therefore  light : 

R. — Piilv.  sinapis.     .......      5ss. 

Pulv.  seiiiin.  lini        ......      5viij. — Misce. 

Vesication,  in  my  opinion,  very  rarely  expedites  the  cure  or  benefits 
the  patient.  The  ordinary  fly-blister  should  never  be  employed ;  and 
if  it  be  thought  best  to  vesicate,  cantharidal  collodion  should  be  pre- 
scribed for  this  purpose.  A  safe,  almost  painless,  and  at  the  same  time 
efficient,  mode  of  applying  this,  is  in  spots  as  large  as  a  ten-cent  piece, 
half  a  dozen,  more  or  fcAver  according  to  the  extent  of  the  inflammation, 
the  skin  of  course  remaining  sound  between  them.  This  mode  of  ap- 
plication obviates  the  danger  of  producing  a  troublesome  sore,  which 
sometimes  occurs  in  children  from  the  ordinary  mode  of  vesication. 

In  cheesy  pneumonitis,  which  is  always  accompanied  by  anaemia, 
and  great  reduction  of  the  vital  powers,  carbonate  of  ammonium  with 
citrate  of  iron  and  ammonium  equal  parts,  or  cod-liver  oil  administered 
three  times  daily  with  two  drops  or  more  of  syrup  of  iodide  of  iron,  Avill 
be  found  useful,  as  is  also  quinine  with  iron.  Patients  require  the 
most  nutritious  diet  and  alcoholic  stimulants.  In  the  local  treatment  of 
this  form  of  inflammation  vesication,  even  so  mild  as  that  by  cantharidal 
collodion,  should  be  avoided. 


CHAPTER    YII. 

PLEURITIS.i 

The  term  plcuritis  or  pleurisy  is  employed,  in  this  chapter,  to 
designate  inflaunnation  of  the  pleura,  when  not  produced  by  extension 
of  the  inflammatory  process  from  the  lung,  or  by  the  irritation  of 
tubercles  upon  or  under  the  pleura.      Catarrhal  pneumonia,  common  in 

>  From  the  New  York  Obstetric  Journal,  1880-1881. 


FREQUENCY.  G23 

infancy;  croupous  pneumonia,  common  in  childhood;  pulmonary  tuber- 
culosis, not  rare  in  hoth  periods  in  wasted  and  cachectic  children,  are 
ordinarily  accompanied  by  pleurisy,  arising  consecutively  to  the  lung 
disease,  and  limited  nearly  to  the  portion  of  the  pleura  Avhich  covers 
the  affected  lobes  or  lobules.  But  since  in  these  cases  the  pleuritis  is 
subordinate  to  and  dependent  on  the  graver  diseases,  and  is  compara- 
tively unimportant,  it  does  not  require  separate  consideration.  It  is 
properly  treated  of  in  our  books  in  connection  with  and  as  a  part  of 
those  diseases.  All  other  cases  of  pleuritic  inflammation,  although  pre- 
senting Avide  differences  in  form  and  clinical  history,  are  embraced  under 
the  general  term  2)1'' urit is. 

Pleuritis  :  its  frequency. — Pleuritis  was  formerly  supposed  to  be 
rare  in  young  children.  Even  M.  Bai'rier,  of  Lyons,  the  author  of  a  cred- 
itable treatise  on  diseases  of  children,  wrote  as  late  as  1860 :  "  Ainsi  done, 
en  generalisant  les  faits  de  Vallieux  et  les  notres,  nous  pouvons  dire : 
que  la  pleurisie,  depuis  la  naissance  jusquA,  I'age  de  six  ans  environs,  ne 
constitue  presque  jamais  une  affection  simple,  unique,  et  independante 
de  la  pneumonic."  But  greater  precision  in  the  examination  of  cases, 
more  accurate  means  of  diagnosis,  more  knowledrje  of  the  nature  of  dis- 
eases,  and  more  frequent  autopsies  have  enabled  the  profession  to  cor- 
rect this,  as  well  as  many  other  errors ;  and  it  is  now  known  that 
primary  pleurisy  is  not  infrequent  in  young  children,  even  in  infants. 
In  asylums  and  hospitals  fur  children,  in  Avhich  institutions  the  nature 
of  diseases  is  more  accurately  ascertained  than  in  private  practice — for 
autopsies  are  made  in  the  fatal  cases — the  frequency  of  pleurisy  in  its 
various  forms:  latent,  semi-fibrinous,  and  purubnt,  is  surprising  to 
those  Avhose  knowledge  of  the  disease  has  been  acquired  only  through 
private  practice.  Thus,  in  the  New  York  Foundling  Asylum,  in  the 
seven  months  from  April  1  to  November  1,  1879,  while  there  were 
35  cases  of  bronchitis,  21  of  pneumonia,  and  3  of  tuberculosis,  there 
were  11  clearly  ascertained  cases  of  pleurisy.  There  can  be  no  doubt 
that  many  cases  of  this  malady  in  young  children  are  mistaken  by  good 
practitioners  for  other  diseases,  especially  fov  pneumonia,  or,  if  the 
pleurisy  be  to  a  certain  extent  latent,  for  remittent  or  malarial  fever, 
or  fever  due  to  intestinal  irritation.  I  have  records  of  several  cases 
occurring  in  family  and  hospital  or  asylum  practice,  in  which  children 
perisheil  with  a  wrong  diagnosis,  or  without  diagnosis,  when  the  post- 
mortem examination  revealed  pleurisy,  sometimes  of  long  standing. 
Thus  in  one  case  of  fatal  empyema,  commencing  at  the  age  of  six 
months,  and  continuing  several  months,  chronic  pneumonia  had  been 
diagnosticated  by  physicians  known  to  be  thorough  in  their  examina- 
tions, and  usually  accurate.  In  another  case,  which  proved  fatal  at 
about  the  age  of  one  year,  the  child,  who  lived  in  a  malarial  locality, 
had  been  for  weeks  under  treatment  for  supposed  malarial  disease; 
but  in  this  case  diagnosis  was  easy,  for  at  my  first  visit,  which  Avas 
Avhen  the  child  Avas  dying,  there  was  decided  dulnc^s  on  percussion  over 
the  right  side  of  the  chest.  In  this  case,  the  right  lung  Avas  adherent 
to  the  ribs  anteriorly  and  laterally,  while  posteriorly  it  Avas  separated 
by  pus,  which  croAvded  forAvard  the  organ,  so  that  its  posterior  surface 
Nva.s  ccncave. 


624: 


P  L  E  U  R I  T  I  S  . 


In  vrards  of  institutions  and  in  the  crowded  quarters  of  tlie  poor, 
pleurisy  appears  to  be  more  frequent  than  in  families  in  comfortable 
circumstances.  Its  frequency  varies,  also,  in  ditl'erent  years,  according 
to  the  presence  and  prevalence  of  its  causes.  Thus,  during  epidemics 
of  scarlet  fever,  it  is  more  common  than  at  other  times. 

During  several  weeks  immediately  preceding  2^Iay,  1874,  Avhen  there 
was  no  unusual  prevalence  of  the  causes  or  conditions  which  give  rise 
to  pleurisy,  I  noted  carefully  the  character  of  the  sickness  in  404  con- 
secutive cases,  under  the  age  of  twelve  years,  in  private  practice,  and 
of  these,  two  had  primary  pleurisy,  or  one-half  per  cent.  This  is  prob- 
ably about  the  usual  ])ro;)ortion  of  pleurisies  in  cliildreu  in  iamily  prac- 
tice, except  when  scarlet  fever  is  prevalent. 

I  have  preserved  the  records  of  56  cases  of  pleurisy  in  children 
under  the  ages  of  twelve  years,  most  of  them  occurring  in  the  institu- 
tions which  I  am  attending,  or  have  attended  as  physician,  and  the 
remainder  in  private  practice.  The  statistics  of  these  cases,  embraced 
in  the  following  table,  are  interesting,  as  showing  the  frequency  of 
pleurisy,  and  pleurisy  of  the  suppurative  form,  in  young  children.  The 
large  number  of  empyemas  seen  in  the  table  does  not,  however,  indicate 
the  true  proportion  of  suppui-ative  to  sero-fibrinous  pleurisies,  since 
protracted  and  stubborn  cases,  Avhich  are  largely  empyemas,  are  more 
frequently  brought  to  institutions  for  treatment  than  are  those  of  a 
milder  and  more  manageable  type.  Thus,  in  the  class  of  children's 
diseases  in  the  Bureau  for  the  Relief  of  the  Outdoor  Poor,  a  large  per- 
centage of  the  cases  are  empyemas  which  have  resisted  treatment  else- 
where. Besides,  pleurisy  with  little  exudation  is  sometimes  latent  or 
so  mild  that  it  is  overlooked  or  not  diagnosticated,  even  by  physicians 
who  are  thorough  and  careful  in  their  examinations,  and  I  do  not  doubt 
tliat  such  cases  have  occurred  in  the  institutions  and  in  my  private 
jjractice  during  the  time  in  which  my  statistics  were  collected. 


Af/e.     40  Cfl.ses. 

Under  2  Mos. 

From  2  to  G  3Ios. 

From  6  to  12 

Mos. 

From  1  Yr.  to 
3  Vrs. 

From  ?>  Yr3.  to 
6  Yrs. 

Over  G  Yrs. 

o;  all  erapv- 

15 ;   nine  at 

2 ;  both  em- 

13  ;    eight 

10  ;    seven 

li;  five  riijht, 

emas  ;    one 

least   em- 

P3'emas; 

rifflit,  five 

ri-;ht, 

one   left, 

double. 

pyemas  ; 

one  richt, 

left. 

three  left. 

one   em- 

seven   on 

the    other 

Exudation 

Exudation 

pyema. 

rit;ht 

left. 

in  some 

in   some 

side,   four 

sero- 

sero- 

on  left 

fibrinous  ; 

fibrinous; 

side,   four 

in  others 

in  others 

dmiblo. 

pm-ulent. 

purulent. 

Causes. — The  common  cause  of  primary  pleuritis  is  the  same  as  that 
of  other  idiopathic  inflammations,  namely,  "  taking  cold."  It  is,  there- 
fore, most  common  in  times  of  changeable  temperature.  Cachexia  is 
an  acknowledged  predisposing  cause,  so  that  children  whose  blood  is 
impoverished,  whether  from  ju-evious  disease  or  from  anti-hygienic  in- 
fluences, are  more  liable  to  this  inflammation  than  those  who  possess  a 
sound  and  vigorous  constitution.     From  the  operations  of  these  two 


CAUSES.  625 

causes  a  larger  proportion  of  cases  occur  among  the  children  of  the  city 
poor  than  among  those  who  are  well  nourished  and  who  live  in  com- 
fortable circumstances,  since  the  cachectic  and  ill-cared  for  arc  not  only 
more  exposed,  but  are  les3  able  to  resist  noxious  agencies. 

Pleurisy  is  not  rare  in  newborn  infants,  and  its  cause,  when  thus 
occurring,  is  not  always  apparent.  It  may  sometimes  be  heedless 
exposurs  to  cold  or  to  currents  of  air  by  the  nurse,  but  the  common 
cause  at  this  age  is  believed  to  be  the  absorption  of  septic  matter. 

Billard,  wliose  observations  were  made  amonoj  foundlino-s  in  the  Hos- 
pice  des  Enfants  Trouves,  says :  "  Pleurisy  is  more  common  among 
young  infants  than  is  generally  supposed;  it  often  appears  without  the 
lungs  participating  in  the  inflammation.  I  have  seen  several  infants 
die  immediately  after  birth  from  this  affection."  He  relat!-\s  two  cases 
of  double  idiopathic  pleuritis  ending  fatally  at  the  ages  of  two  and  ten 
days  [Diseases  of  Infants,  page  419).  Mignot,  wdiose  observations  were 
made  in  tlie  same  institution,  also  records  ten  pleurisies,  five  of  which 
were  idiopathic,  in  119  dissections  of  newborn  infants  [Maladies  pe7i- 
dant  Je  Premier  Af;e). 

Cases  like  the  following  are  not  infrequent: 

In  1<*^67,  I  made  the  post-mortem  examination  of  a  foundling  who  died 
in  the  New  York  Infaut  Asylum,  at  the  age  of  about  one  month.  On 
each  side  of  the  thorax,  the  pleura,  costal  and  pulmonary,  Avas  uniformlv 
injected,  and  a  small  amount  of  pus,  not  more  than  one  drachm,  was 
found  in  one  pleural  cavity,  and  a  still  let^s  qua^itity  of  pus  in  the  other, 
with  little  or  no  sero-fibrinous  exudation.  There  was  also  pus  at  the  root 
of  each  lung,  lying  not  entirely  upon  the  free  surface  of  the  pleura,  but 
])artly  underneath  it. 

The  fact  of  a  double  pleurisy  without  disease  of  the  lungs,  which 
might  produce  it,  indicated  a  constitutional  cause.  Its  system  had 
probably  become  infected  by  the  absorption  of  septic  matter  from  the 
umbilical  vessels. 

One  of  the  eruptive  fevers,  scarlatina,  not  infrequently  produces  pleu- 
ritis, occurring  as  a  complication  or  sequel.  This  result  seems  to  be 
sometimes  due  to  the  altered  state  of  the  blood,  resulting  from  the  pres- 
ence of  the  scarlatinous  virus.  In  otlier  instances  it  is  probably  the 
result  of  retained  urea,  consequent  on  scarlatinous  nephritis,  for 
pleuritis  is  a  common  complication  of  Bright's  disease,  due,  it  is  sup- 
posed, to  the  irritating  property  of  urea,  which  is  excreted  upon  the 
pleural  surface.  Pleuritis,  in  young  children,  is  sometimes  also  caused 
by  the  discharge  into  the  pleural  cavity  of  some  morbid  product,  as  pus, 
softened  tubercle,  or  decomposed  lung-tissue,  which,  from  it:^  iiighly  ir- 
ritating effect,  causes  intense  and  general  inflammation  of  the  pleura. 
I  have  observed  several  such  cases. 

Thus,  in  Xovember,  1800,  an  infant  of  three  and  a  half  months  died  of 
pleurisy,  occurrin<^  upon  the  left  side.  Tiie  left  lung  was  firmly  hound 
down  l)y  adhesions,  so  as  to  be  reduced  to  about  one-sixth  its  normal 
size.  On  attempting  inflation  of  this  ()r<ran,  when  it  was  removed  from 
the  body,  air  escaped  from  a  small   t)pening  in  the  middle  of  the  ui)[>er 

40 


626  PLEURITIS. 

lobe,  and  around  this  opening  the  lung-substance  ■was  of  a  dark  reddish 
color,  softened  and  disintc^grated.  It  seemed  probable  from  the  appear- 
ance that  there  had  been  hypostatic  congestion,  or  pcrhai)S  pneumonia,  in 
the  posterior  ])art  of  the  lung,  and  that  the  loss  of  vitality  imd  softening 
had  occurred  from  the  sluggish  or  suspended  circulatii)n  in  the  part,  and 
that  the  fatal  pleurisy  had  resulted  from  a  little  of  this  decomposed  tissue 
entering  the  pleural  cavity. 

A  case  having  apparently  a  similar  origin  occurred  in  the  New  York 
Foundling  Asylum  in  October,  187*J. 

An  infant,  aged  five  montlis  and  a  half,  became  suddenly  and  severely 
sick  Avith  pleurisy  on  the  right  side,  and  died  in  five  days.  On  opening 
the  pleural  cavity,  air  escaped.  The  record  of  the  examination  states : 
"  In  about  the  middle  of  the  posterior  surface  of  the  lower  lobe -was  an 
opening  whicli  adaiitted  the  tip  of  the  little  finger  to  the  depth  of  one- 
fourth  to  one-third  inch.  The  lung-tissue  seemed  to  be  disorganized,  and 
of  pultaceous  consistence  around  the  (uivity.  Through  this  cavity,  which 
counnunicated  with  a  bronchial  tube,  the  air  had  escaped,  which  was 
noticed  on  opening  the  chest." 

Occasionally  we  meet  cases,  especially  in  foundling  asylums,  in  which 
the  cause  is  different  from  the  foregoing,  but  in  some  respects  similar. 
An  indolent  pneumonitis  occurs  over  a  circumscribed  area  in  the  pos- 
terior part  of  the  lung,  either  from  hypostasis  or  exposure  to  cold. 
Minute  abscesses  form  in  the  inflamed  parench3nna,  not  larger  than 
pins'  heads  or  small  shot.  Perhaps  they  are  located  in  bi'onchioles,  and 
are  produced  by  the  accumulation  of  muco-pus  Avhich  collects  in  these 
tubes,  and  is  not  expectorated  on  account  of  the  low  vitality  and  feeble 
functional  activity  of  tlie  tissues  concerned.  These  abscesses  approach- 
ing the  pleural  surface  produce  a  circumscribed  pleuritis  of  small  extent ; 
and  finally  one,  probably  in  some  sudden  movement  of  the  lungs,  as  in 
crying  or  coughing,  breaks  into  the  pleural  cavity,  causing  general  puru- 
lent inflammation.     The  following  was  such  a  case: 

In  May,  18o9,  a  male  infant,  aged  two  months,  was  admitted  into  the 
Nursery  and  Child's  Hospital.  He  was  delicate,  and  had  what  was  diag- 
nosticated a  mild  bronciiial  catarrh ;  but  by  wet-nursing  his  general  con- 
dition gradually  improved.  In  July,  however,  he  had  repeated  attacks 
of  diarrlioja,  and  progressively  lost  flesh  and  strength.  On  August  3d  his 
respiration  became  suddenly  accelerated  and  painful,  and  death  occurred 
from  dyspniea  and  exhaustion.  No  cough  or  other  symptoms  referable 
to  the  respiratory  apparatus  had  been  observed  i)reviously  to  the  day  of 
death. 

At  the  autopsy  tlie  intestines  were  found  to  pi-esent  the  usual  lesions  of 
intestinal  catarrh  of  the  summer  season.  The  i-ight  lung  was  compressed 
]\V  a  sero-fibrinous  exudation,  though,  from  the  small  size  of  the  ])leural 
cavity,  the  quantity  of  exuded  liquid  was  not  more  than  two  ounces. 
Nearly  the  entire  right  pleura,  visceral  and  parietal,  was  covered  with 
fibrin  of  a  creamy  appearance,  and  there  were  loose  flocculi  in  depending 
portions  of  the  cavity.  This  lung  could  be  inflated,  except  a  little  of  the 
lower  lobe,  which  was  hepatized.  The  left  lung  also  occupied  a  very  small 
space,  being  partially  collapsed.     It  could  be  readily  inflated,  when  it  ap- 


CAUSES.  627 

peared  normal,  except  a  small  portion  in  the  posterior  aspect  of  the  lower 
lobe,  which  ^vas  partially  covered  with  lymph,  and  was  found  to  coutaio 
two  abscesses,  one  closed  and  the  other  opening  externally  on  the  surface 
of  the  lung,  and  connecting  internally  with  the  bronchial  tube.  On 
attempting  inflation,  air  passed  directly  thi-ough  this  opening.  The  closed 
al)scess  contained  from  one-third  to  onedialf  a  drachm  of  pus  and  disin- 
tegrated lung-tissue,  as  shown  by  the  microscope. 

Another  case  showing  a  similar  cause  of  pleurisy  occurred  in  a  female 
infant  of  about  four  months,  in  the  same  institution,  in  November, 

1869. 

She  was  admitted  in  October,  somewhat  reduced  from  diarrhoea,  but 
her  health  improved  partially,  though  she  remained  feeble,  and  the 
records  state  that  she  was  much  troubled  with  meteorism  and  occasional 
pain  On  ^November  2d,  she  was  suddenly  seized  with  great  dyspn(ea, 
and  died  in  about  fifteen  minutes.  No  cough  had  been  noticed  or  other 
symptom  referable  to  the  chest,  but  there  can  be  little  doubt  that  the 
occasional  symptoms  of  pain,  referred  to  in  the  notes,  were  due  to  the 
pleurisy.  The  body  was  much  emaciated,  and  depending  portions  showed 
hypostatic  congestion  ;  right  lung  adherent  to  diajjhragm  and  to  a  con- 
.siilei'able  pnrt  of  the  costal  pleura  by  fibrinous  exudation  ;  this  lung  was 
somewhat  compressed  and  non-crepitant ;  its  upper  lobe  floated  in  water, 
while  its  middle  and  lower  lobes  sank,  and  could  be  only  partially  in- 
flated; this  |)ortion  of  the  lung  contained  a  few  small  superficial  abscesses, 
each  holding  scarcely  more  than  one  drop  of  /pus ;  two  of  these  were 
empty,  and  air  passed  through  them  on  attempting  inflation.  They 
probably  one  or  both  opened  into  the  pleural  cavity  during  life,  but  pos- 
sibly they  were  opened  in  separating  the  adhesions  which  united  the  two 
pleural  surfaces  at  this  point ;  the  pleural  cavity  contained  from  two  to 
three  ounces  of  liij^uid,  consisting  mainly  of  pus  and  fibrinous  shreds. 

A  similar  case  occurred  in  the  New  York  Foundling  Asylum,  in 
October,  1879. 

The  patient,  aged  four  months,  began  to  be  sick  October  11th,  having 
the  characteristic  symptoms,  and  died  October  loth.  The  right  pleural 
cavity  contained  about  5i!J  of  sero-purulent  liquid,  pressing  the  lung  f  )r- 
ward  and  toward  the  median  line.  In  the  posterior  surface  of  the  right 
lower  lobe,  near  its  base  and  immediately  under  the  pleura,  Avere  three  or 
four  small  al)scesses,  each  not  larger  than  a  small  drop  of  pus,  and  two 
or  perhaps  three  of  these  had  ruptured,  so  that  air  escaped  from  them  on 
attem|)tii)g  inflation,  while  one  was  closed,  the  pus  in  it  being  visible  under 
the  pleura. 

This  cause  of  pleurisy,  namely,  the  bursting  of  a  minute  abscess  in 
the  lung,  and  that  in  which  a  portion  of  the  lung  loses  its  vitality,  dis- 
integrates, and  enters  the  pleural  cavity,  are  probably  rare,  except  in 
the  first  months  of  infancy  in  wasted  and  ill-conditioned  infants,  in 
families  of  the  city  poor  and  in  the  asylums. 

A  peri-pharyngeal  abscess,  descending  along  the  ocso[)hagus,  has  been 
known  to  cau.se  fatal  pleuritis  by  burstin;;  into  the  pleural  cavity,  and 
pus  from  carious  vcrtebrcv;  has  produced  the  same  result.     In  January, 


628  PLEURITIS. 

IBG-i,  I  presented  to  tlie  New  York  Pathological  Society  the  lungs  of 
au  infant  whose  history  was  as  follows: 

R.,  aged  nine  months,  of  strumous  parentage,  and  whose  only  sister  had 
suffered  severely  from  strumous  ophthalmia  and  periostitis,  was  taken  sick 
about  December  19,  I8G0,  with  fel)rile  movement,  attended  by  restless- 
ness, but  apparently  without  any  ."^erious  indisposition.  On  the  22d,  the 
mother  called  my  attention  to  a  ju-ominence  just  below  the  right  clavicle, 
which  proved  to  be  au  abscess,  and  a  })oultice  was  applied  over  it.  On  the 
24th,  tlie  proniiuence  suddenly  subsided,  and  immediately  the  symptoms 
■were  greatly  aggravated.  The  pulse  rose  to  IGt)  ])er  minute,  the  res[)ira- 
tion  from  GO  tt)  60,  and  expiration  Avas  aceom})anied  by  a  moan,  indi- 
cating acute  pleuritic  or  pulmonary  intiammation.  Within  forty-eight 
hours  after  the  disa})pearance  of  the  swelling,  and  the  exacerbation  of 
symptoms,  dulness  on  percussion  over  the  right  side  of  the  chest  was 
observed,  and  this  increased  till  it  was  complete  from  the  clavicle  to  the 
base  of  the  thorax.  The  acceleration  of  pulse  and  respiration  continued, 
the  patient  grew  more  and  more  feeble,  and  death  occurred  December 
?,lst. 

On  dissecting  away  the  integument  from  the  right  side  of  the  chest,  an 
abscess  was  opened,  containing  neai-ly  one  ounce  of  pus,  located  at  the 
point  where  the  tumor  had  been  observed.  At  the  base  of  this  abscess, 
between  two  of  the  ribs,  was  a  small,  round  opening,  not  much  larger  than 
a  knitting-needle,  leading  directly  into  the  cavity  of  the  chest,  so  that 
on  depressing  the  ribs  liquid  flowed  back  from  the  pleural  cavity.  On 
removing  the  sternum  the  liquid  was  found  to  be  sero-fibrinous,  with  con- 
siderable pus  in  depending  portions  of  the  cavity. 

I  have  met  one  other,  apparently  almost  identical  case,  occurring  in 
an  infant  of  seven  months. 

Pleurisy  in  the  adult  is  sometimes  the  result  of  violence.  The  most 
notable  and  unequivocal  cases,  having  this  origin,  are  those  in  which  the 
ribs  are  fractured.  It  rarely  happens  that  we  can  attribute  the  pleurisy 
of  children  to  this  cause.  I  can  recollect  only  one  case  in  which  the 
inflammation  seemed  to  be  due  to  violence. 

In  September,  18G7,  an  infant  of  twenty-tAvo  months,  in  the  Almshouse 
on  Blackwell's  Island,  having  had  a  cough  for  half  a  year,  and  being  some- 
Avhat  reduced,  fell  from  bed,  striking  against  the  left  side  of  the  thorax. 
Severe  pleuritic  symptoms  supervened,  and  the  child  died  of  empyema 
in  three  and  a  half  weeks.  More  than  a  pint  of  pus  was  found  in  the 
left  pleural  cavity,  pressing  the  heart  beycmd  the  median  line,  and  the 
diaphragm  downward,  so  that  it  Avas  convex  toAvard  the  abdomen.  The 
bronchial  glands  Avere  hyperplastic  and  slightly  cheesy,  and  a  caseous 
nodule  lay  in  the  anterior  surface  of  the  right  lung,  Avhich  seemed  other- 
Avise  healthy.  The  left  lung  bound  down  by  adhesions  could  be  partially 
inflated.  Whether  or  not  it  contained  small  tubercles  is  not  stated  in  the 
records. 

The  occurrence  of  the  injury  just  before  the  commencement  of  the 
pleurisy  may  indeed  have  been  a  coincidence,  but  the  motlier  constantly 
believed  that  the  fall  caused  the  inflammation,  and  there  was  no  other 
assignable  cause. 

It  is  probable,  from  the  history  of  this  case  and  the  lesions,  that  the 


AXATOMICAL    CHARACTERS.  629 

cheesv  degenerations  antedated  the  fall,  and  that  the  pleura  was  in  an 
abnormal  state  and  prone  to  intiammation  when  the  injury  was  received. 

The  etiology  of  pleurisy  in  children  differs,  therefore,  from  that  in 
adults.  Certain  causes  are  the  same  ;  but  others,  as  scarlet  fever,  and 
irritating  products  generated  in  the  walls  of  the  chest  and  bursting  into 
the  pleural  cavity,  are  not  rare  in  infancy  and  childhood,  while  they 
seldom  occur  in  adults. 

Anatomical  Characters. — iix  '■he  commencement  of  pleuritis,  the 
subpleural  bloodvessels,  lying  in  the  connective  tissue,  and  the  capilla- 
ries of  the  pleura  are  engorged  with  blood,  producing  vascular  points 
and  arborescence,  seen  through  a  magnifying-glass  of  low  power. 
Frequently,  in  children  as  in  adults,  minute  extravasations  of  blood, 
resulting  from  extreme  congestion,  occur  under  the  endothelial  layer, 
perhaps  scarcely  perceived  by  the  naked  eye,  but  readily  seen  under  the 
glass.  Immediately  exudation  of  liquid,  holding  numerous  cells,  begins 
in  the  connective  tissue  which  surrounds  the  capillaries,  the  pleura 
becomes  dry  and  lustreless,  while  the  production  and  exfoliation  of  its 
endothelial  cells  are  greatly  increased.  These  no  longer  present  their 
normal  appearance,  but  are  swollen  and  granular,  in  consequence  of  the 
inflammation. 

Immediately  after  these  parenchymatous  changes  occur,  serum,  fil^rin- 
ogenic  substance,  and  leucocytes  begin  to  exude  upon  the  free  surface  of 
the  pleura.  The  term  fibrinogenic  substance,  instead  of  fibrin,  is  em- 
ployed, because  it  is  noAV  believed  that  fibrin  itself  is  not  exuded,  but  a 
substance  which  becomes  fibrin,  through  the  presence  and  action  of  cer- 
tain agents  with  which  it  comes  in  contact,  among  which  may  be  men- 
tioned air,  red  blood-corpuscles,  and  even  serum,  from  which  fibrin  has 
been  precipitated  (Virchow,  Cornil,  Ranvier,  and  others). 

In  the  exuded  liquid,  even  if  it  have  the  appearance  to  the  naked  eye 
of  ordinary  scrum,  the  microscope  always  reveals  the  presence  of  pus- 
cells  or  leucocytes,  and  red  blood-cells,  however  small  their  quantity 
may  be.  The  minute  rootlets  of  the  lymphatic  system,  which  are  inter- 
spaces or  lacunjB  in  the  subpleural  connective  tissue,  and  which,  here 
and  there,  open  by  stomata  upon  the  pleural  surface,  are  clogged  by  in- 
flammatory products,  and  their  walls  swollen  at  an  early  stage  (E. 
Wagner  and  others).  In  these  lymphatic  channels,  both  pus-cells  and 
coagulated  fibrin  are  seen  by  the  microscope.  That  pneumonitis, 
whether  catarrhal  or  croupous,  seldom  occurs  in  superficial  parts  of  the 
lungs  without  causing  inflammation  of  that  portion  of  the  pleura  which 
covers  the  aff'ected  lobules  is  universally  known  :  but  the  reverse  is  also 
true,  that  pleurisy  seldom  occurs  without  causing  inflammation  of  the 
alveoli  which  are  adjacent  to  the  inflamed  membrane.  The  pneumonitis 
thus  caused  is  so  superficial  that  it  is  very  liable  to  be  overlooked  at  the 
post-mortem  examination,  in  the  presence  of  the  graver  lesions  of  the 
pleura;  but  a  knowledge  of  its  occurrence  is  important  in  diagnosis, 
for,  though  it  may  have  no  greater  depth  than  a  line,  it  is  sufficient  to 
produce  crepitant  rales,  like  those  in  ordinary  pneumonitis.  Therefore, 
if  we  hear  these  rales,  we  may  mistake  the  disease  for  pulmonary  in- 
flammation and  overlook  the  pleuritis — an  error  not  unusual  in  the 
treatment  of  children.     Trousseau,  who  surpassed  most  of  his  contempo- 


630  PJ.EURITIS. 

raries  as  a  clinical  observer,  wrote  :  "  This  sound,  which  is  met  ^Yith  in 
the  great  mujority  of  cases  of  pleurisy,  is  in  fact  a  crepitant  nlle,  and  I 
have  called  it  a  crepitant  rale  of  pleurisy.  My  interpretation  is  very 
simple.  Just  as  we  never  have  erysipelas  without  engorgement  of  the 
cellular  tissue,  there  cannot  be  erysipelas  of  the  pleura  or  pleurisy  with- 
out an  irritative  engorgement  of  the  subpleural  cellular  tissue  or  of  the 
peripheric  pulmonary  parenchyma.  This  Huxion  naturally  carries  with 
it  into  the  pulmonary  vesicles  a  serous  exudation.  .  .  .  We  also  meet 
with  a  fine  subcrepitant  ntlc,  which  is  very  often  heard  quite  at  the 
beginning  of  pleurisy,  and  which  likewise  nearly  always  continues  for 
some  weeks."  More  recent  observers  and  writers  fully  agree  with  the 
statement  of  Trousseau,  except  that  what  he  designates  irritative  en- 
gorgement the  microscope  sho\YS  to  be  a  true  inflammation  of  the  pul- 
monary alveoli. 

There  are  four  constituents  of  every  pleuritic  exudation,  namely, 
serum,  fibrin,  red  blood-corpuscles,  and  leucocytes  or  pus-cells,  Avhich  last 
are  identical,  in  apjiearance,  with  the  white  blood-corpuscles  and  the 
lymph-corpuscles,  and  the  origin  of  which  has  been  investigated  by 
many  microscopists.  It  is  convenient  to  classify  cases  of  pleuritis 
according  to  the  quantity  and  relative  proportion  of  these  constituents 
as  follows:  1st.  The  plastic,  sometimes  designated  dry  or  adhesive. 
2d.  The  sero-fibrinous.  3d.  The  purulent.  4th.  The  hemorrhagic. 
In  cases  which  pertain  to  the  first  group,  the  inflammation  is  chiefly 
parenchymatous,  either  no  exudation  occurring  upon  the  free  surface  of 
the  pleura,  or  if  any,  whether  fibrin,  pus,  or  serum,  it  is  so  slight  that 
it  possesses  no  clinical  importance.  The  essential  anatomical  changes 
in  this  form  of  pleuritis,  as  regards  the  pleural  surface,  are  rapid  pro- 
liferation, retrogressive  change,  or  decay  and  exfoliation  of  the  endothe- 
lial cells,  and  the  sprouting  out  of  granulations  which  develop  into 
connective  tissue.  In  plastic  pleuritis,  there  is  no  compression  of  the 
lungs,  and  the  pleural  surfaces  are  separated  from  each  other  only  by 
the  granulations  Avliich  soon  unite  with  those  of  the  opposite  surfiice. 
This  form  of  pleuritis  is  not  infrequently  latent  in  children,  for  at  the 
autopsies  of  those  who  have  died  of  various  diseases  we  often  observe 
bands  of  connective  tissue,  uniting  the  opposite  pleural  surfaces,  when 
the  parents  or  nurses  cannot  recall  to  mind  any  sickness  or  symptoms, 
such  as  pleuritis  commonly  causes.  It  is  certain,  also,  that  plastic 
pleuritis  is  often  overlooked,  when  not  latent;  the  fever  and  other 
symptoms  being  attributed  to  causes  quite  distinct  from  the  true  one. 
The  symi)toms  and  physical  signs  are  obviously  less  pronounced  in  this 
than  in  other  forms  of  pleuritis. 

2d.  SERO-FiBjaNOUS  PhEURiTis. — This  is  the  most  frecjuent  of  all. 
It  is  the  pleuritis  Avhich  commonly  results  from  catching  cold.  The 
serum  exudes  from  the  ca})illaries  of  the  inflamed  pleura  in  very  variable 
quantity  in  diff'erent  cases,  and  the  pleurnl  surface  is  soon  covered  with 
a  fibrinous  layer.  This  may  be  a  mere  film,  or  it  may  attain  the  thick- 
ness of  half  an  inch  or  more.  It  is  usually  at  first  slightly  attached, 
but  afterward,  from  being  blended  with  the  granulations,  it  may  be 
firmly  adherent.  In  some  cases  it  is  quite  compact,  while  in  others  it 
has  a  loose  areolar  texture,  containing  in  its  interstices  serum  and  pus- 


PUKULEXT    PLEURITIS.  G31 

cells.  The  fibrin  is  for  the  most  part  deposited  on  the  pleura,  hut  shreds 
and  flakes  of  it  also  float  in  the  serum.  In  the  serum,  as  well  as  en- 
tangled in  the  fibrin,  Ave  find  not  only  red  blood-cells  and  leucocytes, 
but  endothelial  cells  thrown  off  from  the  pleura  which,  as  Avell  as  those 
still  adherent,  are  almost  always  in  process  of  degeneration  and  decay. 

If  a  perpendicular  section  be  made  through  the  pleura,  in  this  as  "vvell 
as  in  the  other  forms  of  pleuritis,  many  newly  formed  cells,  the  lymph- 
corpuscles,  are  observed  in  the  meshes  of  the  subpleural  connective 
tissue,  and,  as  we  examine  the  section  nearer  to  the  surface  of  the 
pleura,  these  calls  are  seen  to  be  aggregated  in  masses,  and  held  together 
by  a  structureless,  homogeneous  matrix.  The  lymph-corpuscles  appear 
to  be  the  active  agents  in  the  formation  of  granulations.  They  are  ob- 
served in  various  stages  of  transformation,  from  the  round  to  the  spindle- 
shaped.  The  prolongations  of  the  spindle-shaped  cells  unite  with  each 
other,  so  as  to  form  the  connective  tissue,  capillaries,  and  other  elements 
of  the  granulating  surface.  That  the  endothelial  cells  take  no  part  in 
the  production  of  the  new  tissue  is  inferred  from  the  fact  that  most  of 
them  present  the  appearance  of  retrogressive  change  and  decay.  The 
granulations,  as  they  sprout  out  from  the  pleura,  become  intimately 
blended  with  the  fibrinous- exudation,  and  when  the  effused  liquid  is  ab- 
sorbed, they  unite  with  those  of  the  opposite  pleural  surface,  forming 
an  organic  union,  by  bloodvessels  and  nerves,  between  the  lung  and 
parietes,  the  lung  and  pericardium,  or  different  lobes  of  the  same  lung, 
as  the  case  may  be.  They  pass,  in  two  or  three  weeks,  from  embryonic 
to  perfect  tissue,  vessels  and  nerves  grow  in'  them,  and  they  possess, 
henceforth,  all  the  properties  of  living  tissues  ;  they  are  al)le  to  absorb ; 
they  are  lialjle  to  inflammation  and  hemorrhage,  and  may,  in  fine,  par- 
ticipate in  all  the  alterations  of  the  organism  of  which  they  are  a  part. 
(Jaccoud.) 

3d.  Purulent  Pleuritis. — Although,  as  stated  above,  pus-cells  are 
always  present  in  the  pleuritic  exudation,  we  designate  the  disease  pur- 
ulent or  empyema  when  the  cells  are  so  numerous  as  to  render  the 
liquid  turbid.  If  there  be  cloudiness,  appreciable  to  the  naked  eye, 
and  due  to  the  pus-cells,  the  case  is  regarded  as  one  of  this  form  of 
pleuritis.  Purulent  pleuritis  is,  at  first,  in  a  large  proportion  of  cases, 
sero-fibrinous,  becoming  purulent  after  some  days  or  weeks — a  fact 
readily  ascertained  by  the  use  of  the  hypodermic  syringe  at  diff'erent 
periods.  In  otlier  instances,  the  pleuritis  is  purulent  from  the  first. 
Pleuritis  is,  in  fauiily  and  in  hospital  practice,  more  frequently  purulent 
in  children  than  in  adults,  and  in  ill-conditioned  children  than  in  those 
who  are  robust.  It  is,  therefore,  a)>t  to  be  purulent  in  one  who  has  had 
an  exhausting  disease,  as  scarlet  fever,  and  in  the  cachectic  children, 
who  reside  in  or  are  brought  to  institutions  for  treatment.  Thus,  in  the 
New  York  Foundling  Asylum,  in  1871),  an  infant,  aged  two  months 
and  three  days,  became  feverish,  and  had  the  expiratory  moan  and 
hurried  respiration  characteristic  of  pleuritis.  On  the  fourth  day,  Dr. 
R(>ynolds,  who  was  in  attendance,  inserted  the  hypodermic  syringe  and 
filled  it  with  thin  pus.  This  was,  apparently,  a  case  of  primary  idio- 
pathic empyema.     Pleuritis  is  purulent  when  it  is   produced  by  the 


032  PLEURITIS. 

entrance  of  some  irritating  substance  into  the  pleural  cavity,  as  pus  or 
decomposed  lung-tissue. 

The  production  of  pus  in  the  pleural  cavity  is  often  surprisingly  rapid, 
for,  when  many  ounces  have  been  removed  by  the  aspirator,  nearly  the 
original  quantity  is  sometimes  restored  Avithin  two  or  three  days.  As 
Fraentzel  says,  it  does  not  seem  possible  that  so  many  pus-cells,  Avhich 
must  surpass  in  number  the  aggregate  of  the  white  blood-corpuscles, 
could  Avander  from  the  bloodvessels  in  so  short  a  time,  so  that  we  must 
look  for  some  other  source  of  the  immense  production  of  leucocytes,  in 
addition  to  that  discovered  by  Cohnheim.  A  large  part  of  the  pus- 
cells  is,  in  all  })robability,  produced  by  ra})id  segmentation  of  the  lymph- 
corpuscles.  In  two  cases  of  purulent  jjleuritis,  both  infonts,  I  found 
pus  underlying  the  pleura  near  the  hilus,  without  apparently  any  loss 
of  integrity  in  the  pleura,  in  such  quantity  that  it  Avas  immediately  re- 
cognized by  the  naked  eye.  Pus  under  the  pleura,  as  Avell  as  Avithin  the 
pleural  cavity,  Avas  apparently  due  to  unusual  violence  in  the  inflamma- 
tion, and  ra])id  production  of  leucocytes. 

Heaiorriiagic  Pleuritis. — This  is  not  common,  I  recall  but  one 
case  in  a  child,  in  Avhom  the  pleuritis  occurred  as  a  sequel  of  scarlet 
fever.  The  fluid  several  times  removed  by  the  aspirator  had  a  deep 
reddish-broAvn  color.  I  Avas  apprehensive  that  the  point  of  the  aspirator, 
by  wounding  the  granulations,  had  caused  the  hemorrhage  Avhich  stained 
the  pus  remoAxnl  at  each  subsequent  operation.  But,  Avith  the  care  ex- 
ercised, and  the  great  amount  of  blood-stained  exudation,  it  seems  almost 
certain  that  this  Avas  not  the  true  explanation,  and  that  it  Avas  a  genuine 
case  of  hemorrhagic  pleuritis. 

Hemorrhagic  exudation  in  the  pleuritis  of  children  is  sometimes  due 
to  purpura  hemorrhagica,  being  like  the  other  hemorrhages  a  symptom 
of  the  general  disease.  In  other  cases  it  signalizes  the  commencement 
of  a  ncAV  inflammation  in  the  vascular  granulations  of  a  previous  pleu- 
ritis. Occurring  under  such  circumstances,  it  is  due  to  the  increased 
fluxion  in  the  numerous  delicate  capillaries  of  the  granulations.  Pleu- 
ritis due  to  cancerous  or  tubercular  formations  in  or  upon  the  pleura  is 
sometimes  also  hemorrhagic.  Jaccoud  says:  "A  sero-fibrinous  or 
purulent  exudation  may  be  red  by  the  transudation  of  hematin,  without 
true  hemorrhage  .  .  .  ;  the  red  exudations  Avhicli  have  been  ob- 
served in  scorbutus  and  marsh  cachexia  are  really  due  to  these  pseudo- 
hemorrhages."  In  those  cases  in  Avhich  there  is  true  hemorrhage,  it  is 
still  uncertain  Avhethcr  rupture  of  the  capillaries  or  a  transudation  ordi- 
narily occurs,  or  whether  tlie  blood-cells  may  not  escape  in  both  modes. 

A  liquid  pleuritic  exudation,  whether  sero-fibrinous  or  purulent, 
obviously  produces  an  important  mechanical  cflect  from  its  location. 
In  young  children,  especially  those  enfeebled  by  sickness,  the  expan- 
sive poAver  of  the  lung  is  slight,  so  that  it  readily  yields  to  pressure 
applied  to  its  surface,  and  becomes  more  and  more  compressed  as  the 
liquid  accumulates.  Except  Avhen  retained  by  adhesions,  the  lung  is 
pressed  toward  the  mediastinum,  and  at  the  same  time  carried  forAvard 
and  upward.  Patients  Avith  pleuritis  usually  lie  on  the  back  and  aifected 
side,  so  that  gravitation  determines  to  a  considerable  extent  in  what 
part  of  the  pleural  caA'ity  the  liquid  will  collect.     In  the  considerable 


HEMORRHAGIC    PLEURITI3.  633 

number  of  post-mortem  examinations  which  I  have  witnessed  of  chil- 
dren who  perished  from  plearitis,  chiefly  empyema,  the  hmg  was  usually 
attached  anteriorly  to  the  thorax  from  the  mediastinum  outward,  as  far 
as  the  costo-chondral  articulations,  or  further,  except  in  the  lower  part 
of  the  cavity,  where  there  were  no  adhesions,  or  adhesions  only  near 
the  mediastinum.  There  were  also  attachments  along  the  mediastinum, 
and  attachments  more  or  less  firm  on  all  sides,  anteriorly,  laterally,  and 
posteriorly  in  the  upper  part  of  the  pleural  cavity,  toward  which  the 
lung  was  compressed.  Many  variations  occur,  depending  on  the  amount 
of  li(pud  and  the  extent  of  the  adhesions;  but  judging  from  autopsies 
which  I  have  seen,  I  would  say  that,  in  the  average,  in  cases  so  severe 
that  the  question  of  operative  interference  arises,  if  we  draw  a  line  from 
the  axilla  downward  and  forward  to  the  epigastrium,  the  lung  is  adhe- 
rent to  the  thorax  over  the  space  anterior  and  internal  to  this  line, 
Avhile  external  and  posterior  to  it  the  liquid  separates  the  lung  from 
the  ribs.  This  fact  is  important,  as  indicating  the  proper  point  for 
puncturing  the  chest,  namely,  below  the  lower  angle  of  the  scapula, 
and  between  the  eighth  and  ninth  ribs.  One  reason  why  the  eaidier 
performers  of  thoracentesis  were  so  unsuccessful  was  that  they  selected 
the  anterior  wall  of  the  .chest  as  the  point  of  operation.  Nowadays, 
however,  no  one  would  be  justified  in  performing  thoracentesis  unless 
he  first  employed  the  hypodermic  syringe  and  removed  fluid  at  the 
point  which  he  selects  for  the  puncture.  The  statistics  of  Mohr,  relat- 
ing to  lung  displacement  in  empyema,  chiefly  statistics  of  adult  cases, 
are  somewhat  (liff'erent  from  mv  general  recollection  of  cases  occurring 
in  infancy  and  childhood  as  stated  above.  In  23  cases  he  found  the 
lung  free  from  adhesions,  and  compressed  against  the  vertebral  column 
and  the  mediastinum ;  in  13  cases  the  organ  was  compressed  from 
below  upward;  in  1  from  above  downward;  in  4  from  within  out- 
ward; in  4  from  behind  forward,  and  in  4  from  before  backward. 
These  variations  depend  on  the  adhesions  which  the  lung  happens  to 
contract.  Perhaps  a  point  a  little  external  to  the  perpendicular,  pass- 
ing through  the  angle  of  the  scapula,  is  preferable  for  puncture,  as  I 
have  known  the  lung  to  be  adherent  to  the  posterior  wall  of  the  chest 
near  the  mediastinum,  when  the  portion  further  removed,  say  two  inches 
from  the  median  line,  was  separated  by  interposed  liquid. 

Sometimes  the  liquid  is  collected  in  multilocular  cavities  formed  by 
the  connective  tissue,  and  these  frequently  intercommunicate.  Excep- 
tionally in  children,  as  in  the  adult  cnses  observed  by  Molir,  when  there 
has  been  a  large  and  rapid  liquid  exudation,  or  when  the  disease  has 
been  violent  and  of  short  duration,  adhesions  do  not  occur. 

On  account  of  the  great  difference  in  the  size  of  the  pleural  cavity  at 
different  ages  during  infancy  and  childhood,  the  amount  of  li(|uid  which 
produces  that  degree  of  compression  of  the  lung  which  materially  im- 
pairs its  function,  varies  greatly.  At  the  age  of  four  months,  three 
ounces  j)roduce  complete  collapse  of  lung,  so  that  it  resembles  a  fleshy 
miiss  (carnification).  The  largest  amount  of  liquid  relatively  to  the  size 
of  the  chest,  in  any  of  the  cases  which  I  liave  observed,  was  about  one 
and  one-lialf  pints,  in  the  left  pleural  cavity  in  an  infiint  that  died  at 
the  age  of  twenty-two  months,  in  September,  1867.     The  heart  lay 


634  PLEURITIS. 

chiefly  to  the  right  of  the  median  line,  and  the  diaphragm  was  convex 
toward  the  abdominal  cavity.  The  case  occurred  in  the  Almshouse  on 
Blackwell's  Island,  and  might  in  all  probability  have  been  relieved 
had  attention  been  directed  to  it  suiTiciently  early. 

Liquid  in  the  left  pleural  cavity,  when  considerable,  presses  the  heart 
toward  the  mediastinum,  so  that  the  apex  beat,  instead  of  being  a  little 
internal  to  the-  linea  mammalis,  approaches  the  sternum.  As  the  heart 
is  carried  to  the  right,  the  beat  is  felt  under  the  lower  end  of  the  ster- 
num, and  with  still  greater  increase  in  the  eftusion,  the  pulsation  is 
detected  by  the  finger,  to  the  right  of  the  sternum.  If  the  exudation 
be  on  the  right  side,  the  displacement  of  the  heart  toward  the  left  is,  for 
obvious  reasons,  less  than  the  displacement  toward  the  right,  in  pleu- 
ritis  of  the  left  side.  Much  external  pressure  upon  the  heart  embar- 
rasses its  movements,  and  prevents  proper  filling  of  its  cavities,  while 
the  action  of  the  organ  is  accelerated  so  as  to  compensate.  Therefore, 
the  pulse  is  quick  and  feeble. 

In  one  instance  in  my  practice,  the  lower  extremities,  and  the  portion 
of  the  trunk  below  the  thorax,  became  oedematous,  from  compression  of 
the  ascending  vena  cava,  and  writers  allude  to  cases  in  whicli  other 
vessels  and  ducts,  as  the  thoracic,  were  compressed,  so  as  seriously  to 
embarrass  their  functions.  The  ])aticnt  with  the  oedema  was  a  boy  of 
about  four  years,  with  empyema  of  the  left  side. 

In  large  effusion,  the  mediastinum  is  pressed  against  the  healthy  lung 
so  as  to  diminish  its  transverse  diameter,  and  Traube  has  shown  that 
the  effect  of  this  is  to  increase  the  length  of  the  lung,  or  its  vertical 
measurement.  Consequently  as  the  lung  on  the  healthy  side  extends 
lower  than  in  the  normal  state,  the  convexity  of  the  diaphragm  on  this 
side  is  diminished,  as  well  as  on  the  affected  side,  where  it  is  depressed 
by  the  effusion. 

The  pleura  in  protracted  cases  of  empyema  becomes  much  infil- 
trated, and  from  the  growth  of  connective  tissue  Avhich  blends  with  it, 
is  thickened,  sometimes  to  the  extent  of  one  or  two  lines.  A  few  months 
since,  in  removing  the  lungs  from  the  body  of-  a  young  infant  that  per- 
ished of  empyema  in  the  N.  Y.  Foundling  Asylum,  a  portion  of  the 
costal  pleura,  two  or  three  inches  in  diameter,  being  adherent  to  the 
lungs,  was  detached  from  the  ribs.  It  had  a  thickness  of  fully  two 
lines,  and  its  free  surface  was  rough. 

Occasionally  the  inflammation  extends  from  the  pleura  to  the  pericar- 
dium, producing  general  pericarditis.  I  recall  to  mind  four  cases  with 
this  complication,  in  which  the  diagnosis  was  verified  by  post-mortem 
examinations.  All  had  empyema,  three  on  the  left,  and  one  on  the 
right  side.  Pericarditis,  always  a  grave  disease,  is  almost  necessarily 
fatal  when  thus  occurring  as  a  complication  of  empyema.  JNIoi'e  rarely 
the  inflammation  extends  from  the  ])leura  to  the  peritoneum.  One  such 
case  occurred  in  my  practice,  the  child  dying  of  empyema  on  the  right 
side,  and  at  the  autopsy  Ave  found  the  lesions  of  a  localized  diaphrag- 
matic peritonitis  of  the  right  side,  with  a  fibrinous  exudation  of  small 
extent  on  the  convex  surface  of  the  liver,  directly  opposite  to  that  on 
the  diaphragm.  We  are  indebted  to  Von  Recklinghausen  for  knowl- 
edge of  the  mode  in  which  inflammation  is  propagated  from  the  jjleura 


HEMORRHAGIC    PLEURITIS.  635 

to  the  peritoneum,  and  the  same  explanation  probably  applies  to  its 
propagation  to  the  pericardium.  In  the  serous  covering  of  the  dia- 
pliragm,  pleural  and  peritoneal,  minute  stomata  have  been  discovered, 
Avhich  pertain  to  the  lymphatic  system.  They  open  upon  the  surface 
of  the  diaphragm,  and  underneath  in  the  substance  of  the  diaphragm 
connect  ^svith  lacuni^  or  interspaces,  from  Avhich  the  minute  lymphatic 
vessels  originate.  These  stomata  and  lymphatic  spaces,  pervious  in 
their  normal  state,  are  usually  clogged,  as  has  been  stated  above,  by  in- 
flammatory products,  Avhen  the  serous  membrane  is  inflamed.  Occa- 
sionally the  inflammation  traverses  these  lymphatic  channels  from  one 
surface  to  the  other, -from  the  pleura  to  the  peritoneum,  thus  causing  by 
extension  a  circumscribed  peritonitis. 

The  changes  which  the  inflammatory  products  undergo  are  the  follow- 
inn^:  With  the  abatement  of  the  inflammation,  the  liquid  portion  begins 
to  be  absorbed,  though  abs(jrption  is  much  more  tardy  than  in  non-in- 
flannnatory  effusions,  since  the  absorbents  are  to  a  great  extent  covered, 
and  clogged  by  filjrin  and  pus.  The  serum  is  first  absorbed,  and  the 
flocculi  of  fibrin  sink  into  dej)ending  portions  of  the  cavity,  or  become 
attached  to  the  fibrinous  layers  or  the  granulations  upon  the  pleural 
surface.  The  pus-cells  and  the  fibrin,  whether  in  flocculi  or  layers, 
begin  to  undergo  retrogressive  change.  They  become  granular  from 
fatty  degeneration,  liquefy,  and  are  absorbed.  Sometimes  portions  of 
these  degenerated  products,  which  are  not  absorbed,  form  inert  caseous 
masses,  in  recesses  of  the  cavity,  or  between  the  bands  of  connective 
tissue,  where  they  remain  unchanged  for  years.  With  few  exceptions, 
those  who  recover  from  an  attack  of  pleuritis  experience  no  subsequent 
ill-effect,  though  the  bands  and  patches  of  connective  tissue  are  perma- 
nent. 

Pus  always  possesses  irritating  properties.  Decomposed  and  putrid 
pus  (ichor)  is  very  irritating.  Empyemic  pus,  therefore,  like  pus  in 
other  situations,  now  and  then  produces  ulceration  or  necrosis  of  the 
pleural  surfiice  by  which  it  is  confined,  and  in  consequence  of  its  de- 
structive action  it  sometimes  establishes  an  outlet  by  which  it  escapes, 
with  relief  of  the  patient  and  cure  of  the  disease.  The  chest  wall  is 
thinnest  antei'iorly,  in  the  inframammary  region,  and  at  this  point  the 
pus,  when  it  makes  its  way  through  the  thoracic  wall,  usually  points 
and  discharges,  Tlie  fistulous  opening  thus  produced  continues  many 
montiis,  until  the  pleural  cavity  is  gradually  obliterated  by  the  adhe- 
sions, and  the  patient  recovers. 

By  a  simihir  destructive  process  in  tlie  pulmonary  pleura,  pus  occa- 
sionally escapes  into  the  bronchioles,  and  is  expectorated.  This  mode 
of  cure  appears  to  be  common  in  children,  for  my  attention  has  not  in- 
frequently been  called  to  the  fact  that  children,  during  the  progressive 
but  slow  convalescence  from  enq)ycma,  expectorated  largo  quantities  of 
muco-pus,  although  in  some  of  the  cases  pus  had  been  removed  by  the 
aspirator  or  trocar.  Fraentzel  makes  the  remark,  which  is  fully  sus- 
tained by  clinical  experience  in  this  country,  tliat  although  an  ojjcning 
is  made  in  the  lung  by  the  necrotic  or  ulcerative  process,  so  that  pus 
escapes  into  the  bronchioles^  air  does  not  j)ass  from  tlicm  into  the  pleural 


63G  PLEURITIS. 

cavity.       Pvopneumothorax  is  very  rare  in  the  empyema  of  children, 
except  as  air  is  admitted  in  the  opei'ation  of  thoracentesis. 

As  the  h(iuid  is  absorbed,  the  compressed  lung  ordinarily  expands  in 
proportion  to  the  absorption,  so  that  more  and  more  air  enters  its  alve- 
oli. But  fre(|UL'ntly,  in  cases  of  long  duration,  the  absorption  proceeds 
faster  than  the  expansion,  so  that  the  ribs  on  the  affected  side  siidc  be- 
low their  normal  level.  As  a  consequence,  the  intercostal  spaces  are 
narrowed,  the  shoulder  is  depressed,  and  the  dorsal  portion  of  the  spinal 
column  bends  to  accommodate  the  ribs  so  as  to  be  concave  toward  the 
aftected  side.  It  is  very  rarely  that  the  deformity  thus  produced  is  per- 
manent. Though  the  newly  formed  bands  and  patches  of  connective 
tissue  may  so  bind  the  lung  that  its  return  to  the  normal  state  is  tardy, 
yet,  Avith  few  exceptions,  the  alveoli  one  after  another  open  to  admit 
air,  and  when  full  inflation  is  attained  the  symmetry  of  the  chest  is 
restored.  But  there  are  rare  cases  in  which  the  newly  formed  connec- 
tive tissue  is  firm  and  unyielding  almost  as  cartilage,  and  lime  salts  are 
sometimes  deposited  in  it,  forming  a  cak-areous  plaque,  which  invests 
the  lung  like  a  cuirass.  An  unexpanded  lung,  with  such  a  covering, 
obviously  can  never  afterward  be  fully  inflated.  I  can  recall  to  mind, 
however,  only  one  case  of  permanent  complete  collapse  or  carnification 
of  lung,  resulting  from  pleurisy.  The  inflammation,  which  was  treated 
by  the  late  Dr.  Cammann,  occurred  in  childhood,  and  several  years 
afterward,  when  the  patient  reached  womanhood,  although  the  general 
health  was  good,  there  Avere  physical  signs  of  an  unaerated  lung,  and 
the  consequent  deformity  (depressed  shoulder  and  ribs,  and  bent  spinal 
column).  Pleurisy  with  its  granulations  and  retrogressive  products 
affords  one  of  the  conditions  in  which  tubercles  are  developed,  so  that 
Ave  sometimes  find  at  the  post-mortem  examination  of  cases  Avhich  have 
been  protracted,  "  miliary  tubercles  in  the  pleura,  Avhile  chronic  phthisis 
and  general  tuberculosis  are  absent  "   (Dclafield). 

From  the  intimate  relation  of  the  heart  to  the  lungs,  this  organ 
obviously  suffers  severely  in  every  large  pleuritic  exudation.  Total 
compression  of  a  lung  arrests  one-half  of  the  circulation  through  the 
pulmonary  artery,  except  as  the  increased  floAv  in  the  opposite  lung 
serves  for  compensation.  Hence,  in  cases  of  large  effusion,  which  end 
fatally,  Ave  commonly  find  the  pulmonary  artery  and  the  right  cavities 
of  the  heart  distended  Avith  blood  and  clots,  Avhile  the  left  cavities, 
having  received  a  diminished  quantity  of  blood,  are  probably  empty. 

Symptoms. — As  has  been  stated  above,  pleuritis  in  children  is  some- 
times latent,  or  attended  by  symptoms  so  mild  as  to  attiact  little  atten- 
tion, even  Avhen  there  has  been  general  inflammation  of  the  pleural  sur- 
fiice  Avith  much  effusion.  Both  primary  and  secondary  pleuritis  may 
present  this  form,  latency  being  more  fre([uent  the  3'ounger  the  patient. 
In  feeble,  cachectic  children,  Avith  blood  thin  and  impoverished,  pleu- 
ritic symptoms,  as  pain,  dyspnoea,  and  fever,  are  less  pronounced  than 
in  the  robust,  and,  hence,  latency  is  more  common  in  the  tenement- 
house  population  of  the  cities  and  in  institutions  than  in  the  better 
Avalks  of  life.  The  following  is  a  not  infre(juent  example  of  latency.  A 
feeble  infant,  aged  five  months  and  twenty-eight  days,  died  suddenly  in 
the  Nursery  and  Child's  Hospital,  in  December,  1870.     The  attention 


SYMPTOMS.  637 

of  the  resident  physician  had  not  been  called  to  it,  as  it  was  not  sup- 
posed to  be  sick,  except  that  it  was  ill-nourished  and  its  general  condi- 
tion bad.  The  nurse  who  had  charge  of  the  ward  stated  that  it  presented 
no  sjinptom  of  acute  disease,  unless  a  slight  cough  during  the  three  or 
four  dijs  preceding  its  death.  Percussion  over  the  right  side  of  the 
chest  of  the  corpse  gave  a  flat  resonance,  and  at  the  autopsy  the  righi 
lung  was  found  compressed,  nearly  or  quite  destitute  of  air,  and  cov- 
ered by  a  loose  fibrinous  layer,  three-fourths  of  an  inch  thick  in  places, 
and  a  moderate  serous  exudation. 

Ordinarily  acute  idiopathic  pleuritis  in  children  begins  quite  abruptly, 
and  with  symptoms  Avhich  attract  attention  fi'om  the  first.  Probably  in 
most  instances  it  is  preceded  by  rigors,  or  a  chilly  sensation,  but  this 
usually  escapes  notice,  if  it  be  present,  in  patients  under  the  age  of  fiv^e 
or  six  years.  Fev^er,  fretfulness,  and  a  physiognomy  indicative  of  pain 
are  the  common  initial  symptoms.  If  the  patient  be  an  infant,  the 
fretfulness  closely  resembles  that  produced  by  colic,  f  >r  Avhich  I  have 
on  several  occasions  known  it  to  be  mistaken  by  the  attending  physi- 
cians. 

The  symptoms  of  pleuritis  are  tAvofold,  namely,  tlie  constitutional,  or 
such  as  are  common  to  all  inflammations,  and  the  local,  or  those  refer- 
able to  the  chest.  Various  observers  have  noted  the  position  in  Avhich 
patients  lie  in  bed,  as  indicating  the  seat  of  the  inflammation.  It  has 
been  stated  that  adults,  in  the  commencement  of  pleuritis,  ordinarily 
obtain  most  relief  with  a  decubitus  on  the  sound  side,  but  when  eff"usion 
has  occurred  they  lie  on  the  affected  side,  unless  there  be  marked  dys- 
pnoe.i,  which  is  most  relieved  by  a  semierect  position,  which  allows 
greater  descent  of  the  diaphragm.  I  have  not  noticed  that  children 
with  pleuritis  prefer  any  fixed  or  uniform  position,  except  there  be 
marked  dyspnoea,  which  may  prompt  them  to  elevate  the  shoulders. 
The  patient  in  the  acute  stage  is  commonly  quiet  when  he  lies  in  the 
po-jition  which  he  selects,  and  if  disturbed  from  it  becomes  more  fretful, 
his  cough  more  frequent,  an<l  his  suffering  a])parently  increased. 

In  ordinary  cases,  the  temperature  rises  on  the  first  day  to  102°  or 
108^.  If  it  be  more  elevated  than  this,  there  is  usually  a  complica- 
tion. The  fever  begins  to  abate  when  the  exudation  has  occurred.  In 
suppurative  pleuritis,  the  febrile  movement  is  more  protracted,  often  con- 
tinuing for  weeks  or  months,  presenting,  after  the  acute  stage  has  passed, 
the  cliaracters  of  hectic  fever  with  morning  abatement  and  evening  re- 
crudescence. In  weakly  and  aniBmic  children,  even  when  the  pleuritis 
is  pretty  severe,  and  most  of  the  usual  symptoms  are  present,  the  tem- 
j)erature  may  be  but  slightly  elevated.  Thus,  in  one  of  the  institu- 
tions with  which  I  am  connected,  a  young  infant,  whose  fretfulness  was 
during  the  first  twenty-four  hours  ascril)ed  to  colic,  the  axillary  tem- 
perature during  the  first  three  days  never  rose  above  100°. 

The  pulse  in  the  acute  stage  is  usually  between  100  and  1^0  per 
minute,  but  in  young  children  who  are  restless  it  is  often  more  frequent 
than  this  during  the  first  week.  It  is  accelerated  as  long  as  the  tem- 
perature is  elevated,  l)ut  in  sero-fibrinous  jileuritis,  after  exudation  has 
occurreil,  its  fiv(|uen('y  diminishes  uidess  the  heart  be  compressed.  Com- 
pression and  imi)erfect  or  partial  filling  of  the  cavities  of  the  heart  pro- 


638  PLEURITIS. 

duce  a  feeble  and  rapid  pulse.     In  empyema  the  pulse  is  accelerated  as 
lono-  as  pus  is  confined  in  the  pleural  eavit\',  unless  its  quantity  he  small. 

Headache,  usually  frontal,  is  frequent  during  the  febrile  stage.  Con- 
vulsions, which  occasionally  occur  in  the  beguuung  of  pneumonitis,  are 
rare.  Pain  in  the  chest,  on  the  affected  side,  is  common,  and  is,  there- 
fore, a  valuable  diagnostic  symptom,  but  it  is  often  so  slight  as  to  be 
overlooked  in  infants  and  feeble  children.  It  is  increased  by  move- 
ments of  the  chest-walls,  as  in  full  inspiration,  by  coughing,  and  when 
pressure  is  made  by  the  fingers  in  the  examination.  Its  common  seat  is 
between  the  fifth  and  eighth  ribs,  external  to  the  linea  mammalis,  but 
there  are  many  cases  in  which  the  pain  is  referred  to  some  other  part, 
as  the  infraclavicular,  mammary,  inframammai'y,  or  even  the  scapular 
or  infrascapular  region.  Rarely,  it  is  referred  to  the  epigastric  or  um- 
bilical reo-ion,  or  even,  it  is  said,  to  some  point  upon  the  sound  side  of 
the  thorax.  This  location  of  the  pain  at  a  point  distant  from  the  seat 
of  the  inflammation  is  attributable  to  the  anastomosis  of  the  intercostal 
nerves  with  those  of  the  opposite  side  of  the  chest,  or  with  those  which 
ramify  in  the  abdominal  Avails. 

The  pain  of  pleuritis,  as  it  ordinarily  occurs,  has  received  different 
explanations.  It  has  been  attributed  to  tension  of  the  pleura,  to  fric- 
tion of  the  pleural  surfaces  on  each  other,  and  to  extension  of  the  in- 
flammation to  the  neurilemma  of  the  minute  nervous  branches  of  the 
pleura.  All  these  causes  apparently  act  in  producing  it,  but  the  per- 
sistent pain  in  the  first  days  of  pleuritis,  though  increased  by  motion,  is 
probably  due  in  great  part  to  that  last  mentioned.  Pleuritic  pain  is 
sharp  01-  stitch-like.  It  begins  to  abate  in  a  few  days,  and  in  a  large 
proportiou  of  cases  ceases  by  the  fifth  or  sixth  day,  or  is  no  longer 
noticed  except  in  coughing  or  during  sudden  movement  of  the  chest. 

The  respiration  is  accelerated,  as  in  all  febrile  diseases,  but  it  is  more 
rapid  than  in  inflammatory  ailments  which  do  not  involve  the  thoracic 
organs,  on  account  of  the  pain  experienced  on  full  inspiration.  The 
patient  instinctively  avoids  full  inflation  of  the  lungs,  and  the  breathing 
IS  consequently  rapid,  to  compensate  for  incompleteness  of  the  inspira- 
tory act. 

In  ordinary  attacks  of  pleuritis,  painful  and  hurried  respiration  is  of 
short  duration.  It  becomes  easier  and  more  natural  toward  the  close 
of  the  first  week.  In  subacute  and  chronic  cases,  the  rhythm  and  fre- 
Cjuency  of  respiration  differ  but  little  from  the  normal. 

A  cough,  whatever  the  form  of  pleuritis,  is  one  of  the  earliest  symp- 
toms. It  is  short,  frequent,  and  dry,  and  in  the  most  favorable  cases 
begins  to  diminish  in  the  second  week.  A  loose  cough  is  due  to  accom- 
panying bronchitis,  or  broncho-pneumonitis,  or,  at  a  late  stage  of  the 
disease,  to  escape  of  pus  from  the  pleural  cavity  into  the  bronchial  tubes. 

Little  need  be  said  in  regard  to  symptoms  referable  to  the  digestive 
apparatus.  Vomiting  is  common  on  the  first  and  second  days.  Thirst, 
loss  of  appetite,  and  consequent  loss  of  flesh  and  strength,  are  uniformly 
present.  In  empyema,  which,  from  its  nature,  is  protracted,  nutrition 
is  always  greatly  impaired.  The  surface  presents  an  anaemic  appear- 
ance, tiie  flesh  is  soft  and  flabby,  and  the  emaciation  is  progressive  till 
the  pus  is  evacuated. 


PALPATIOX.  639 

Physical  Signs. — In  children  above  the  age  of  three  or  four  years, 
the  physical  signs  differ  but  little  from  those  in  adult  cases,  but  under 
this  age  there  are  certain  diflerences  which  the  practitioner  should  know. 
^Ye  may,  in  the  commencement  of  the  attack,  notice  diminution  in  the 
mov^ement  of  the  chest-walls  on  the  affected  side,  since  the  patient  in- 
stinctively endeavors  to  repress  respiration  on  that  side,  in  order  to 
lessen  the  pain.  In  severe  cases,  the  epigastrium  and  hypochondria  are 
sometimes  depressed  during  inspiration  (the  so-called  abdominal  respira- 
tion ).  but  this  sign  is  less  common  and  less  marked  than  in  severe  bron- 
chitis, and  when  present  it  may  be  largely  due  to  accompanying  bron- 
chitis. After  effusion  has  occurred,  and  the  pain  has  abated  or  is  slight, 
the  respiration  is  less  accelerated  than  at  first,  and  it  may  be  nearly  or 
quite  normal. 

Inequality  of  the  two  sides  produced  by  the  liqtiid  is  more  common 
in  chihlren  of  an  advanced  age  than  in  those  under  the  age  of  three  or 
four  years.  In  infants,  even  when  there  is  a  large  liquid  exudation,  the 
bulging  is  often  so  slight  that  it  is  scarcely  appreciable,  either  by  sight 
or  measurement,  and  in  not  a  few  there  is  no  apparent  difference  in  the 
circumference  of  the  healthy  and  affected  sides.  I  have  made  meas- 
urements in  infantile  pleuritis  during  the  stage  of  effusion,  and  been 
unable  to  convince  myself  that  there  was  any  difference,  although  otlier 
signs  indicated  the  presence  of  an  effusion  which  filled  at  least  one-half 
the  pleural  cavity.  I  explain  this  fact  in  this  way.  The  lungs  of  an 
infant,  especially  of  one  reduced  by  sickness,  are  very  liable  to  a  state 
of  semi-collapse  or  partial  inflation  in  their  'Svliole  extent,  and  of  com- 
plete collapse  of  their  thin  borders,  as  of  the  tongue-like  process  of  the 
left  upper  lobe,  which  lies  over  the  pericardium  and  of  the  margins  of 
the  lower  lobes,  which  lie  on  the  angle  made  by  the  thorax  or  diaphragm. 
This  occurs  in  the  weakly  infant,  even  when  there  is  no  obstruction  to 
the  entrance  of  air,  and  the  liability  to  it  is  greatly  increased  by  ex- 
ternal pressure  applied  to  the  lung,  as  from  a  pleuritic  effusion,  so  that 
the  lung  recedes,  becomes  compressed,  and  unaerated,  before  the  ribs 
yiebl  to  the  pressure.  If  the  exudation  cease  as  soon  as  the  lung  is 
collapsed,  there  is  little  or  no  outward  displacement  of  the  ribs,  and  the 
intercostal  spaces  are  not  elevated.  It  is  obviously  very  important  to 
know  this  difference  between  inflmtile  and  adidt  cases,  as  it  has  a  bear- 
ing upon  the  diagnosis  between  pleuritis  with  effusion  and  pneumonitis. 

Palpatiox. — tn  adults,  and  in  children  with  strong  voices,  if  the 
lung,  deprived  of  air  either  by  compression  or  an  exudation  within  its 
alveoli,  lie  against  the  chest-wall,  speaking  or  moaning  produces  a  vib- 
ratory sensation  which  is  communicated  to  the  hand  placed  upon  the 
chest.  The  fremitus  is  feeble  or  not  appreciable  when  the  voice  is 
feeble.  Therefore,  in  infints  whose  vocal  cords  arc  small,  and  particu- 
larly in  infants  reduced  by  sickness,  this  sign  is  ordinarily  absent,  or  so 
slight  that  it  is  detectcil  with  difficulty,  while  in  older  and  robust  cliil- 
dren  it  is  distinctly  perceived.  If  the  condition  be  otherwise  favorable 
for  the  production  of  fremitus,  but  the  lung  be  pressed  away  from  the 
ribs  by  an  intervening  lirpiid,  no  vibration  is  felt  when  the  patient 
speaks  or  cries.  But  if,  in  tlio  same  case,  the  fingers  be  removed  to  the 
suprascapular,  axillary,  infraclavicular,  or  mammary  region,  where  the 


640  PLEURITIS. 

compressed  lung  comes  in  contact  with  the  walls  of  the  chest,  fremitus 
may  be  perceived.  Palpation  also  enables  us  to  ascertain  the  point  of 
apex-beat  of  the  heart,  variation  of  Avhich  from  the  normal  site  being 
one  of  the  most  conclusive  proofs  of  a  pleuritic  effusion. 

Percu^^sion. — In  the  first  hours  of  pleuritis,  there  is  either  no  per- 
ceptible change  in  the  percussion  sound,  or  the  resonance  is  slightlj 
diminished,  from  the  fact  that  inspiration  on  the  affected  side  is  resisted 
by  the  patient,  and  the  lung  is  only  partially  inilated.  When  exuda- 
tion occurs,  if  there  be  a  thin  layer  of  liquid  over  the  lung,  the  percus- 
sion sound  is  tympanitic.  It  has,  therefore,  this  quality  at  an  early 
stage  in  the  inframammary,  mammary,  and  perhaps  infrascapular 
re""ions,  when  the  amount  of  liquid  is  small,  and  at  a  later  stage,  wiicn 
the  quantity  of  liquid  is  greater,  the  percussion  sound  over  the  lower 
part  of  the  chest  is  dull,  Avhile  that  over  the  central  or  upper  part  is 
tympanitic.  Entire  filling  of  the  pleural  cavity  with  liquid,  and  total 
exclusion  of  air  from  the  lung,  give  rise  to  a  dull  or  fiat  percussion 
sound  over  every  part,  from  the  apex  to  the  base.  It  may  be  stated  as 
a  rule  in  the  pleuritis  of  children  that,  at  a  certain  stage  of  the  effusion, 
percussion  produces  a  sound  which  is  either  decidedly  tympanitic  or 
which  partakes  of  the  tympanitic  character.  Skoda  attrilDuted  the  oc- 
currence of  tympanism  to  the  fact  that  a  lung  still  aerated  vibrates 
better  if  surrounded  by  a  thin  layer  of  liquid,  and  consequently  gives 
better  resonance  than  when  it  lies  against  the  chest-walls. 

"When  the  exudation  is  so  great  that  the  lung  is  totally  compressed, 
and  removed  to  a  distance  from  the  chest-walls,  the  finger  in  percussing 
experiences  a  sensation  of  solidity  or  resistance,  and  there  is  no  longer 
any  vibration  of  the  ribs.  Consequently  the  percussion  sound  is  dull 
or  flat,  as  over  any  solid  body,  dift'cring  from  that  in  pneumonitis,  in 
Avhich  there  is  still  some  vibration  of  the  chest-walls,  and  the  dulness  is 
not  absolute.  In  pleuritis,  therefore,  there  is,  according  to  the  amount 
of  exudation,  either  nearly  the  normal  percussion  sound,  as  at  the  be- 
ginning of  the  attack  and  in  any  stage  of  plastic  pleurisy  (pleuresie 
seche),  or  a  zone  of  dull  sound  below,  and  another  of  tympanitic  sound 
above,  or  a  zone  of  normal  resonance  above,  and  one  of  dull  resonance 
at  the  base,  with  an  intervening  one  of  tympanism,  or,  finally,  there  is 
absolute  dulness  from  the  clavicle  to  the  base  of  the  chest. 

It  very  rarely  happens  in  the  child  that  the  level  of  the  fluid  changes 
by  changing  the  position,  on  account  of  the  adhesions,  so  that  this  sign, 
described  in  the  books  as  one  of  great  importance  in  diagnosis,  affords 
very  little  assistance  to  diagnosis  in  children. 

Auscultation. — In  the  beginning  of  pleuritis,  auscultation  afforda 
but  slight  information,  except  tlint  tlie  practised  ear  may  detect  a  little 
diminution  in  the  fulness  of  the  respiratory  act  in  the  lung,  whose 
pleura  is  inflamed,  and  perhaps  a  slightly  exaggerated  respiration  in 
the  other  lung.  But  after  twelve  or  fifteen  hours,  when  exudation  be- 
gins to  occur  upon  tlie  pleural  surface,  we  may  hear  the  dry  friction 
sound,  which  can  be  imitated  by  pushing  the  finger  strongly  across  the 
dry  palm  of  the  hand.  It  is  only  heard  in  occasional  cases,  since  the 
physician  may  not  make  his  visit  at  the  proper  time  for  hearing  it,  or 
he  does  not  apply  the  ear  over  the  proper  place.     Fraentzel  says: 


AUSCULTATION.  641 

"  We  shall  scarcely  ever  fail  to  find  the  friction  sound,  in  recent  pleu- 
ritis,  if  Ave  look  for  it  early  and  diligently  in  some  circumscribed  spot." 
I  do  not  think  that  this  remark,  however  true  it  may  be  of  adult  cases, 
is  entirely  correct  as  regards  children,  for  it  is  only  in  exceptional  in- 
stances that  it  can  be  heard  in  them.  It  occurs  both  during  inspira- 
tion and  expiration,  and  it  does  not  disappear  after  coughing.  Being 
produced  ui»on  the  surface  of  the  lung,  it  seems  near  the  ear  of  the  aus- 
cultator.  Perhaps  it  is  not  observed  during  several  consecutive  respira- 
tions, and  then  a  deeper  inspiration  causes  the  pleural  surfaces  to  glide 
upon  each  other,  and  it  is  detected.  The  friction  sound  as  sometimes 
heard  is  well  expressed  by  the  term  scraping,  and  in  other  cases  by  the 
term  creaking,  as  was  noticed  by  Hippocrates,  who  compared  it  to  the 
creaking  of  leather. 

In  some  patients  it  is  heard  for  a  brief  period  and  does  not  recur,  and 
it  may  be  detected  only  during  strong  and  deep  respiration  or  in  cough- 
ing. It  disappears  entirely  Avhen  the  accumulation  of  liquid  prevents 
contact  of  the  surfaces.  After  absorption  of  the  liquid,  the  friction 
sound  may  reappear,  and  in  certain  patients  it  is  heard  only  at  this 
time,  to  wit,  in  the  third  stage. 

An  interesting  and  common  sound  heard  on  inspiration  is  the  so- 
called  crepitant  rCde  of  pJenrisy,  produced  in  the  superficial  alveoli. 
The  remarks  made  by  Trousseau  upon  it  have  been  already  given.  As 
stated  above,  tiie  inflammation  extends  from  the  pleura  to  the  pulmonary 
vesicles  which  lie  directly  underneath,  and  as  soon  as  exudation  occurs 
within  them,  the  anatomical  conditions  are  present  in  which  the  crepi- 
tant rale  is  produced,  as  in  the  ordinary  form  of  pneumonitis.  This 
rale  may  obviously  be  heard  before  any  effusion  takes  place  upon  the 
free  surface  of  the  pleura,  and  it  continues  until  the  alveoli  are  so  com- 
pressed by  the  pleuritic  exudation  that  they  no  longer  admit  air. 

The  exudation  in  the  pleural  cavity  changes  the  character  of  the  res- 
piratory sound.  A  thin  layer  of  liquid  over  the  lung  causes  diminution 
in  the  force  of  the  vesicular  murmur,  and  soon  an  expiratory  as  well  as 
an  inspiratory  sound  begins  to  be  heard.  This  modified  vesicular  mur- 
mur is  weak,  and  more  distant  from  the  ear  than  the  respiratory  sound 
of  health.  When  the  exudation  is  sufficient  to  close  the  alveoli,  while 
the  air  still  traverses  the  medium-sized  bronchial  tubes,  we  notice  a 
tubular  or  bronchial  bruit.  If  the  small  and  medium-sized  tubes  are 
compressed,  while  the  air  enters  the  large  tubes,  the  resi)iratory  bruit 
may  be  amphoric.  Total  absence  of  respiratory  sound  results  from 
complete  collapse  of  the  alveoli,  and  conscfptent  exclusion  of  air  from 
them,  and  arrest  of  the  movements  of  the  air  in  the  tubes  of  the  affected 
side.  Jaccoud  says:  "  Regarded  as  a  sign  of  the  quantity  of  the  effu- 
sion, the  modifications  of  the  respiratory  bruit,  and  of  the  respiration, 
may  then  be  arrange  I,  in  an  increasing  series  as  follows :  diminution 
of  the  vesicular  murmur;  feeble  respiration  (.som/^«  doux)\  no  sound, 
ami  feeble  resjtiration  ;  bronchial  respiration;  no  sound,  and  briuichial 
respiration  ;  no  sound,  and  cavernous  respiration  ;  general  al)sence  of 
sound  {silence  f/eneral).  The  replacement  of  an  inferior  term  of  the 
series  by  a  su]>eri(»r  term  implies  an  augmentation  in  the  (piantity  of 
li(j[uid,  and  in  general  the  passage  of  a  superior  term  to  an  inferior  term 

41 


642  PLEURITIS. 

denotes  a  diminution  of  the  effusion."  But  this  statement  relating  to 
the  effect  upon  the  auscultatory  sounds  of  the  increase  and  decrease  of 
the  liquid  nmst  be  modified  as  regards  patients  under  the  age  of  five 
years.  In  such  patients  it  is  rare,  however  great  the  effusion,  that  res- 
piration is  not  heard  when  the  ear  is  placed  over  the  liquid.  This  is 
due  to  the  small  size  of  the  pleural  cavity,  and  the  consequent  ready 
transmission  of  sound  from  the  centre  of  the  thorax  to  its  periphery. 
According  to  the  amount  of  exudation  and  the  degree  of  compression, 
the  respiratory  sound  is  a  faint  and  distant  vesicular,  or  broncho-vesicu- 
lar, or  bronchial  murmur,  and  its  character  is  found  to  vary  from  one 
to  tlio  other  of  these  sounds,  as  we  apply  the  ear  over  different  parts  of 
the  chest. 

When  the  inflammation  is  active,  and  the  exudation  occurs  rapidly, 
bronchial  respiration  may  be  heard  as  early  as  the  second  or  third  day, 
or  even  by  the  close  of  the  first  day,  in  the  infrascapular  region.  If, 
on  the  other  hand,  the  inflammation  be  chiefly  plastic,  or  the  exuda- 
tion of  liquid  Ije  slow,  and  its  quantity  small,  the  rcs]iiratory  murmur 
may  be  vesicular,  though  faint  and  distant,  during  the  whole  course  of 
the  attack.  Sometimes  wdien  the  murmur  is  vesicular  in  the  greater 
part  of  the  lung,  broncho-vesicvdar  or  bronchial  respiration  is  heard 
over  a  limited  area,  where  the  ePmsion  happens  to  be  sufficient  to  pro- 
duce requisite  compression  of  the  lung. 

The  voice  of  the  patient,  wdien  auscultated  over  the  affected  side, 
has  a  character  which  corresponds  with  and  varies  according  to  the  res- 
piratory murmur.  Vocal  resonance  is  feelde  or  absent  if  the  respira- 
tory murmur  be  vesicular.  If  it  be  bronchial,  the  auscultated  voice  is 
more  distinct,  having  the  character  known  as  bronchophony,  or  when 
there  is  a  moderate  quantity  of  li(|uid  over  the  lung,  so  that  this  organ 
vibrates,  it  may  have  that  modification  of  bronchophony  known  as  lego- 
phony.  Occasionally  we  can  hear  the  voice  as  a  confused  and  distant 
sound,  when  the  quantity  of  liquid  is  so  great  that  respiration  is  in- 
audible. The  signs  derived  from  the  auscultated  voice  are  not,  as  is  well 
known,  pathognomonic  of  liquid  effusion.  Broncliophony  is  more  com- 
mon and  distinct  in  pneumonic  or  tubercular  solidification  of  lung  than 
in  pleuritis,  and  even  {legophony  may  be  produced  without  the  presence 
of  a  liquid,  by  "  pleural  membranes  realizing  certain  physical  con- 
ditions" (Jaccoud).  But  since  the  auscultated  voice  is  weaker  in  chil- 
dren than  in  adults,  we  often  do  not  hear  it  in  infants  and  ill-conditioned 
children,  even  when  the  anatomical  conditions,  as  regards  the  lungs  and 
pleural  cavity,  are  favorable  for  its  transmission. 

In  children  as  in  adults,  bronchial  rales  are  common  in  pleuritis,  dry 
or  moist ;  coarse  when  produced  in  the  larger  tubes,  or  fine  Avhen 
occurring  in  the  finer  tubes. 

Diagnosis. — Ordinarily,  a  careful  observance  of  the  history,  symp- 
toms, and  ])hysical  signs  enable  the  physician  to  make  a  positive  diag- 
nosis. Obscure  or  doubtful  cases  occur  chiefly  in  infancy.  Circum- 
scribed pleuritis,  or  pleuritis  attended  with  little  or  no  liquid  exudation, 
is  obviously  likely  to  be  overlooked,  and  its  symptoms  mistaken  for 
another  disease. 

Pleuritis,  before  the  stage  of  exudation,  may  be  mistaken  for  pneu- 


DIAGNOSIS.  643 

monitis,  since  the  prominent  symptoms  in  the  commencement  of  the 
two  diseases  are  similar.  But  in  pleuritis  there  are  commonly  greater 
acceleration  of  pulse  and  respiration,  greater  suffering,  as  evinced  by 
the  features,  greater  tenderness  on  percussion,  or  on  pressing  the  chest- 
wall,  and  a  more  decided  expiratory  moan,  while  the  patient  probably 
endeavors  to  repress  respiration  on  the  affected  side,  so  that  inflation  of 
the  lun<;s  is  partial  and  shallow.  It  Avill  aid  in  the  diagnosis  to  recol- 
lect  that,  in  children  under  the  age  of  five  years,  acute  pneumonitis  is, 
in  most  instances,  catarrhal,  and  not  croupous,  an<l  is  preceded  and 
accompanied  by  severe  bronchitis,  being  due  to  downward  extension  of 
the  inilammation  from  the  bronchial  tubes.  It  therefore  does  not  begin 
with  the  abruptness  of  pleuritis. 

Pleuritis  with  effusion  may  be  mistaken  for  pneumonitis  in  the  stage 
of  solidification,  for  hydrothorax,  or,  on  the  left  side,  for  pericardial 
effusion,  or  vice  versa.  But  the  percussion  sound  over  a  pleuritic  exu- 
dation is  either  tympanitic  or  flat,  while  over  a  lung  solidified  by  inflam- 
mation it  has  some  resonance,  though  dull.  There  is  also  a  sensation 
of  greater  resistance  and  solidity  in  percussing  over  a  pleuritic  exuda 
tion  than  over  an  inflamed  lung.  ^Moreover,  the  respiratory  murmur, 
whether  vesicular,  broncho-vesicular,  or  bronchial,  is  more  distant  and 
less  distinct  to  the  ear  of  the  auscultator  when  applied  over  a  liquid 
than  over  a  solidified  lung. 

A  pleuritic  exudation,  unless  slight,  also  changes  the  apex-beat  of 
the  heart,  pressing  it  toward  the  median  line  in  left  pleuritis,  and  away 
froni  the  median  line  in  right  pleuritis,  as  lias  been  stated  above — a 
change  not  observed  in  pneumonitis.  Bulging  of  the  intercostal  spaces, 
expansion  of  the  chest-walls,  change  in  the  height  of  the  fluid  by  change 
in  the  position  of  the  child,  important  signs  in  the  diagnosis  of  adult 
])leuritis  are,  as  we  have  seen,  commonly  absent  in  young  children,  even 
when  there  is  abundant  lifjuid  effusion,  but  they  are  sometimes  observed 
in  children  of  a  more  advanci'd  age.  Bronchophony  and  vocal  fremitus, 
signs  of  pneumonic  solidification,  are  absent,  or  so  feeble  in  the  pneu- 
monitis of  young  children  that  their  absence  cannot  be  regarded  as 
indicative  of  the  presence  of  pleuritic  effusion,  except  in  children  over 
the  age  of  four  or  five  years.  Moreov^er,  these  signs,  when  present,  do 
not  necessarily  indicate  pneumonitis,  for  if,  in  pleuritic  effusion,  the  ear 
or  han<l  be  place  1  over  a  ])art  of  the  chest  where  adhesions  have  united 
the  lung  to  the  ribs,  and  the  child  be  of  such  an  age  that  the  vocal  cords 
have  sulficient  vibration,  both  bronchophony  and  the  fremitus  may  be 
perceived.  The  absence  or  presence,  therefore,  of  vocal  fremitus  and 
bronchophony  affords  only  limited  assistance  in  the  differential  diagnosis 
of  pleuritis  and  pneumonitis  in  young  children.  In  those  of  an  ad- 
vanced age  whose  vocal  cords  have  greater  vibration  it  aids  in  the  dis- 
criininatinu  of  doubtful  cases,  es])ecially  if  the  examination  be  made  in 
the  infraseapular  region,  which  corresponds  with  the  location  of  the 
liquiil,  if  any  be  present. 

A  pleuritic  effusion  is  distinguished  from  hydrothorax  by  the  fact 
that  the  latter  is  usually  bilateral  and  of  slow  increase,  without  symp- 
toms referable  to  the  chest,  except  when  there  is  considerable  effusion, 
which  causes  more  or   less  dyspnoea.     Pleuritis,  unlike  hydrothorax, 


6i4  PLEURITIS. 

causes  fever  and  otner  constitutional  symptoms,  and  also  a  cough,  pain 
in  the  chest,  and  early  embarrassment  of  res})ii-;ition.  Moreover,  hydro- 
thorax  seldom  occurs,  except  from  cardiac  or  renal  disease,  or  scarlet 
fever. 

A  greatly  distendeil  pericardial  sac  simulates,  in  some  degree,  a  pleu- 
ritic effusion  on  the  left  side,  but  the  absence  of  symptoms  "which  pertain 
to  pleuritis,  as  the  cough,  stitch-like  pain  in  the  chest,  tlie  localization 
or  greater  distinctness  of  the  dull  sound  on  percussion,  in  the  cardiac 
region,  absence  or  feebleness  of  the  apex-beat,  and  indistinctness  or  dis- 
tance of  the  heart  sounds,  "will  preserve  the  oljservant  physician  from 
error  of  diagnosis. 

Progxosis. — In  mild  cases  attended  "with  little  exudation,  the  inflam- 
mation soon  begins  to  abate,  and,  by  the  close  of  the  second  "week,  the 
symptoms  have  nearly  disappeared.  In  plastic  aiul  sero-fibrinous  pleu- 
rises,  recovery  may  be  confidently  expected,  unless  there  be  some  grave 
complication,  or  perchance  syncope  sliould  occur  from  large  and  rapid 
effusion.  A  large  effusion,  whatever  its  character,  especially  if  located 
on  the  left  side,  often  causes  such  a  twist  in  the  great  vessels  "within  the 
thorax  as  seriously  to  retard  the  circulation  of  blood  and  endancrer  life. 
In  effusions  of  the  left  side,  the  heart  is  often  carried  so  far  to"ward  the 
right  that  the  ascending  vena  cava,  "where  it  emerges  from  the  central 
tendon  of  the  diaphragm,  is  bent  at  an  angle  so  as  seriously  to  obstruct 
the  return  of  blood  from  the  lower  half  of  the  body,  and  consequently  a 
reduced  quantity  of  blood  reaches  the  right  cavities  and  the  pulmonary 
artery.  The  result  is  a  diminished  flow  of  blood  in  the  systemic  circu- 
lation, with  anremia  of  important  organs,  as  the  brain.  The  great  arte- 
ries connected  with  the  heart  are  also  more  or  less  bent  in  cases  attended 
by  displacement  of  this  organ.  In  effusions  on  the  right  side,  the  right 
auricle  and  ventricle  sometimes  do  not  expand  to  the  normal  extent 
during  the  diastole,  on  account  of  the  pressure  of  the  liquid,  and  the 
result  is  similar  to  that  in  effusions  on  the  leftside,  as  regards  obstructed 
circulation  and  an;iemia  of  important  organs.  Therefore,  patients  "with 
large  pleuritic  effusions,  whether  left  or  right,  are  liable  to  sudden  faint- 
ing and  even  to  fatal  syncope.  Fortunately,  with  our  present  improved 
methods  of  thoracentesis,  children  need  not  perish  in  this  way  if  the 
operation  be  resorted  to  at  the  proper  moment.  There  is  another 
danger.  When,  in  consequence  of  the  exudation,  the  lung  is  so  com- 
pressed that  its  function  is  nearly  or  quite  lost,  the  sound  lung  obviously 
receives  an  augmented  supply  of  blood.  It  is,  therefore,  very  liable  to 
sudden  congestions  and  transudation  of  serum  (oedema).  If  this  occur, 
the  dyspnoea  is  augmented  and  the  condition  is  one  of  utmost  peril. 
Death  may  result  from  this  state. 

The  prognosis  obviously  varies  according  to  the  cause  of  the  inflam- 
mation and  the  quantity  and  nature  of  the  exudation.  Idiopathic  pleu- 
risies do  better  as  a  rule  than  those  which  occur  as  a  complication  or 
sequel  of  some  other  disease.  Absorption  is  more  rapid  in  the  begin- 
ning of  convalescence,  when  the  fluid  is  thin,  than  at  a  later  period, 
when  it  has  greater  consistence.  Fibrin,  whether  flocculent  or  lamin- 
ated, is  necessarily  sloAvly  absorbed,  first  undergoing  fatty  degeneration 
and  li(|uefaction.     Empyenui,  if  not  relieved   by  operative  measures, 


PROGNOSIS.  645 

•continues  many  months,  and  even  after  pus  is  let  out  convalescence  is 
slow.  In  the  very  considerable  number  of  empyemic  cases  Avhich  have 
from  time  to  time  been  brought  to  the  class  of  children's  diseases  in  the 
Bureau  for  the  Relief  of  the  Outdoor  Poor,  the  histories  commonly 
showed  that  the  disease  had  continued  from  three  to  six  months,  with 
progressive  loss  of  iiesh  and  strength.  Nevertheless,  after  proper 
evacuation  of  the  pus  and  establishment  of  a  fistulous  opening,  the 
majority  have  gradually  recovered,  death  in  the  unfavorable  cases  being 
commonly  due  to  extreme  prostration  with  perhaps  fatal  organic 
changes,  as  amyloid  degeneration  and  tuberculosis. 

Secondary  pleuritis  occurring  in  a  reduced  state  of  the  system,  as 
after  scarlet  fever,  and  pleuritis  complicated  by  a  grave  disease,  as  peri- 
carditis or  pneumonia,  are  always  dangerous  to  life. 

It  is  the  common  belief  that  pleuritic  effusions  involve  greater  danger 
on  the  left  than  on  the  right  side,  from  the  fact  that  the  former  pro- 
duces more  immediate  and  direct  pressure  on  the  heart  and  causes  a 
greater  twist  in  the  vessels,  but  Leichtenstern'  states  that,  in  52  cases 
of  sudden  death  from  pleuritic  effusions,  31  were  right  and  20  left 
pleurises.  The  walls  of  the  right  cavities  of  the  heart,  upon  which  the 
liquid  in  the  right  pleural  cavity  directly  presses,  are  thinner  and  there- 
fore more  yielding  than  the  Avails  of  the  left  cavities.  The  records  of 
the  cases  collected  by  Leichtenstern  show  that  sudden  death  sometimes 
results  from  extensive  and  far-reachinw  thrombi  in  the  rijiht  cavities  of 
the  heart  and  in  the  superior  vena  cava,  or  to  emboli  detached  from  the 
thrombi  and  intercepted  in  the  pulmonar}^  artery.  In  grave  cases  at- 
tended by  large  effusion,  sudden  death  sometimes  occurs  after  some 
exertion  on  the  part  of  the  patient,  as  after  vomiting,  severe  coughing, 
or  hurried  rising  to  the  erect  position,  or  lifting  a  heavy  weight.  It  is 
believed  that,  under  such  circumstances,  there  is  a  retarded  flow  of 
blood  through  the  lungs  and  into  the  left  cavities  of  the  heart  and  the 
aorta,  so  that  sudden  and  fatal  aUcBmia  of  the  brain  is  produced. 

As  already  stated,  death  may  occur  in  protracted  cases  from  amyloid 
degeneration  of  important  organs,  as  the  kidneys  and  liver.  This  can 
sometimes  be  detected  by  enlargement  of  liver  and  spleen,  and  the  oc- 
cuirence  of  albuminuria. 

It  is  evident  that  the  prognosis  varies  greatly  according  to  the  degree 
of  dyscrasia.  In  profound  blood-])oisoning,  wliether  scarlatinous,  nvve- 
mic,  or  septicnemic,  j)leuritis  is  always  grave.  Septic  pleuritis,  which 
occurs  for  the  most  part  in  newborn  infixnts,  during  epidemics  of  puer- 
peral fever  is  especially  so.  When  it  has  continued  a  few  hours,  the 
pinched  features  and  rapid  sinking  show  that  we  have  to  deal  with 
something  more  than  an  ordinary  attack.^ 

Pleuritis  is  also  very  severe,  and  ordinarily  fiital.  when  it  is  cauced 
by  the  entrance  of  some  pathological  product  into  the  i)leQVal  cavity,  as 
pus  or  decaying  lung  substance. 

'   Dcufschos  Archiv  fiir  Klin,  ^fwl..  Band  iv. 

'  Tlie  f<»ll()\viii<j  CHSO,  wliicli  •■cciirrcd  in  my  prnciice  diirintr  the  recent  epidemic 
of  initTperHJ  fcvt-r  (IHSl),  may  l'<!  addiKcd  jis  Hti  exiimplc :  ^Sfrs.  I).,  ii  priinipnra, 
WHS  d»'iivered  by  tlie  forceps  uftfM-  a  tedious  labor,  at  1>  r.  M.,  April  (iili.  On  tito 
following  morning  her  temperature,  without  the  occurrence  of  a  chill,  had  risen  to 


64:6  PLEURITIS. 

Treatment. — It  vrill  be  convenient,  in  considering  the  treatment,  to 
describe  that  Avhich  is  appropriate  for  each  of  the  three  stages  into  "which 
systematic  writers  have  divided  pleuritis:  First,  the  stage  preceding 
effusion ;  secondly,  that  of  effusion ;  and  thirdly,  that  of  absorption  and 
convalescence.  In  the  beginning  of  the  intlammation,  appropriate 
measures  should  be  promptly  employed  for  the  purpose  of  reducing  the 
inflammation,  and  preventing  or  diminishing,  so  iar  as  ])ossible,  the  exu- 
dation that  soon  follows.  The  abstraction  of  blood  is  now  properly  dis- 
carded in  the  treatment  of  most  inflammations  of  infancy  and  childhood, 
but  in  certain  cases  of  pleuritis  occurring  in  robust  children  over  the 
age  of  four  or  five,  or  even  three  years,  the  early  and  judicious  employ- 
ment of  one  or  two  leeches  diminishes  the  pain  and  apparently  also  for 
a  time  the  febrile  movement  and  the  inflammation.  But  it  may  be 
stated  as  a  rule  that  the  loss  of  blood  is  not  only  not  required,  but  is  in- 
jurious in  all  secondary  pleurisies,  and  in  the  primary  form  after  exuda- 
tion has  occurred.  It  is  injurious  in  all  forms  of  pleuritis  in  pallid  and 
cachectic  children,  and,  therefore,  in  a  large  proportion  of  the  cases  oc- 
curring in  the  tenement-houses  and  institutions  of  the  cities.     The  flow 

105^°,  and  her  pulse  varied  between  125  and  134.  She  was  in  a  critical  state  for 
several  days,  with  a  temperature  varying  between  103°  and  105j°,  and  without  any 
local  symptoms  either  of  metritis  or  cellulitis,  but  finally  recovered.  Tiie  baby, 
healthy  and  vigorous  at  birth,  had  been  allowed  to  obtain  what  nutriment  it  could 
from  the  breast,  but  the  nurse  remarked  that  she  "  never  saw  a  child  sleep  so 
much,"  and  I  gave  very  little  attention  to  it,  as  my  tiuie  was  devoted  wholly  to 
the  mother.  On  the  lOih,  when  four  days  old,  its  sleepiness  ceased,  and  it  became 
constantly  fretful,  as  from  colic,  and  it  refused  to  draw  upon  the  nipple.  Early  in 
the  morning  of  the  11th  I  was  summoned  to  it,  and  was  astonished  at  its  altered 
appearance,  its  shrunken  features,  and  its  evidently  dying  state.  Percussion  upon 
the  right  side  gave  a  flat  res mance  from  the  clavicle  to  the  diaphragm,  and  there 
was  some  nieteorism  in  the  abdomen.  The  thermometer  introduced  into  the  rectum 
showed  no  elevation  of  temperature,  and  no  unusual  heat  of  surface  or  cough  had 
been  noticed  by  the  nurse.  By  active  stimulation  the  infant  lived  till  the  middle 
of  the  afternoon.  The  autopsy  revealed  a  scro-fibrinnus  exudation  filling  the  right 
pleural  cavity,  producing  complete  carnification  of  the  lung,  so  that  it  resembled 
that  of  the  fcetal  state,  and  s^ft  patches  or  flakes  of  fibrin  ujion  the  lungs.  By  an 
oveisight,  tlie  ))eritoneum  was  not  examined.  Cases  like  this,  of  pleuritis  in  the 
newborn,  produced,  it  is  thought,  by  the  wandering  micrococci  of  the  septic  state, 
occur  chiefly  during  epidemics  of  childbed  fever.  Some  years  ago  I  saw  a  newborn 
infant  in  one  of  the  institutions,  whose  mother  had  puer])eral  fever,  die  in  a  similar 
manner,  and  the  autopsy  showed  that  the  cause  was  peiitcmitis.  The  following  ex- 
tracts from  Trousseau's  clinical  lecture  on  erysipidas  of  newborn  infants  will  aid  in 
understanding  such  cases.  Speaking  of  Dr.  P.  Lorain,  he  says:  "During  the  epi- 
demic at  the  maternity,  where  tiiis  able  and  laborious  observer  was  a  resident  pupil, 
he  collected  the  information  of  which  the  following  is  a  summary:  Of  106  stillborn 
infants,  10  were  found  to  have  died  from  peritonitis,  and  3  of  the  mothers  of  these 
10  infants  were  carried  oif  by  puerperal  fever  after  delivery.  Of  193  infants  born 
alive,  50  died  of  the  very  same  aftections  which  proved  fatal  to  the  lying-in  women. 
The  most  frequent  causes  of  death  were  peritonitis,  numerous  abscesses,  jiuruleiit  in- 
fection, phlegmonous  swellings,  erysipelas,  gangrene  of  the  limbs,  putrid  infection, 
or  some  other  remarkable  septic  condition."  .  .  .  "  Mother  and  child  then  are  sub- 
ject to  the  same  morbific  influence."  Further  on,  Trousseau  says  of  the  infant 
aflected  by  this  puerjieral  pf)i-on  :  "  lie  will  cry  incessantly  from  pain.  A  state  of 
restlessness  will  be  succeeded  by  collapse,  which  will  close  the  scent;  on  the  fifth, 
sixth,  or  seventh  day.  On  examining  the  body  after  death,  pus  will  be  found  in 
the  cellular  tissue,  sometimes  stippurative  pleurifsy,  more  frequently  phlebitis  of  the 
umbilical  vein,  or  of  the  vena  porta,  or  peritonitis."  An  interesting  incidental 
fact  shown  by  these  statistics  is  liuit  tlie  cause  of  this  puerperal  disease  of  the  new- 
born is  sometimes  operative  in  the  fcetal  state. 


TREATMENT.  647 

of  blood  from  the  bites  if  leeches  are  employed  should  ordinarily  be 
arrested  after  two  or  three  hours,  but  if  slight  it  may  continue  longer  in 
vigorous  children  of  eight  or  ten  years. 

At  the  first  visit  of  the  physician,  an  emollient  and  slightly  irritating 
poultice  should  be  ordered,  enveloping  the  entire  chest,  to  be  constantly 
Avorn,  except  as  it  is  temporarily  removed  during  the  application  of  the 
leech,  and  the  subsequent  flow  of  blood.  The  poultice  should  be  so 
mildly  irritating  that  it  causes  constant  redness  of  the  skin  Avithout 
pain,  and  it  should  not  be  removed  except  Avhen  a  fresh  poultice  is  pre- 
pared to  replace  it.  Thus  employed  it  produces  constant  dilatation  of 
the  capillaries  of  the  skin,  and,  by  the  fluxion  caused,  diminishes  the 
engorgement  of  the  capillaries  of  the  costal  pleura.  A  poultice  of  com- 
mon mustard,  with  flaxseed  in  powder,  one  part  to  sixteen,  between  two 
pieces  of  muslin,  and  so  wet  that  it  moistens  the  hand  in  holding  it,  pro- 
duces this  effect.  Applied  morning  and  evening,  it  can  be  constantly 
Avorn  without  complaint  of  pain  produced  by  its  irritating  action.  For 
infants  under  the  age  of  eight  months,  I  prefer  the  use  of  plain 
flaxseed,  with  camphorated  oil  smeared  upon  its  under  surface.  The 
oil  may  be  applied  several  times  daily,  Avhile  the  morning  and  evening 
application  of  the  poultice  is  sufficient.  Spongiopilin  or  compresses  of 
flannel  wrung  out  of  hot  water  and  covered  Avith  oil-silk  meet  the  indi- 
cation,  and  possess  the  advantage  of  being  lighter  and  cleaner,  and  more 
readily  applied  than  the  poultice.  Redness  may  be  produced  by  ap- 
pljnng  under  the  spongiopilin  a  single  thickness  of  muslin  soaked  Avith 
camphorated  oil,  or  for  children  of  a  more  advanced  age,  Avith  campho- 
rated oil  and  one-fourth  part  of  turpentine. 

Vesication,  formerly  much  employed,  has  properly  nearly  fallen  into 
disuse  in  the  treatment  of  the  pleuritis  of  children.  While  it  is  liable 
to  increase  the  suffering,  it  has  apparently  no  tendency  to  diminish  the 
inflammation,  in  Avhiehever  stage  employed,  and  there  is  no  certainty 
that  it  stimulates  the  absorbents  and  expedites  the  removal  of  the  li([uid, 
according  to  the  old  theory.  A  case  is  re))orted,  in  the  practice  of  one 
of  the  New  York  physicians,  in  Avhich  a  blister  had  been  applied  Avhen 
the  inflammation  Avas  still  active,  and  at  the  autopsy  the  portion  of  the 
costal  pleura  which  lay  directly  underneath  the  surface  that  had  been 
vesicated  Avas  covered  by  a  thicker  fibrinous  exudation  than  that  upon 
the  contiguous  surface.  The  increased  afllux  of  blood  caused  by  the 
blister  had,  to  appearance,  extended  to  the  costal  pleura,  and  increased 
the  pleuritis.  The  application  of  cold  bandages  around  the  chest,  Avbich 
is  recommended  by  some,  seems  to  aggravate  the  cough  in  certain 
patients,  and  does  not  ordinarily  give  the  relief  of  moist  and  Avarm  ap- 
plications. 

Internal  Jlcniedics. — The  indications  are  to  employ  such  medicines 
as  diminish  tlie  fre(|uent  action  of  the  heart,  and  thus  retard,  in  a  meas- 
ure, the  flow  of  blood  to  the  pleura,  and  such  as  dinjinish  the  pain  and 
frequency  of  the  cough,  Avhich,  by  increasing  the  friction  of  the  pleural 
surfaces,  tends  to  increase  the  inflammation.  For  robust  children  over 
the  age  of  three  years  in  the  first  stage  of  primary  jdeuritis,  the  tincture 
of  aconite  may  be  prescribed,  half  a  drop  for  a  patient  of  three  years, 
and  one  drop  for  one  of  six  years,  every  third   hour  for  two  or  three 


648  PLEURITIS. 

days,  or  until  the  required  eifect  be  produced  upon  the  pulse,  "when  it 
should  be  discontinued.  It  is,  as  a  rule,  too  depressini>;  for  yountfer 
patients.  Digitalis  is  a  better  and  safer  remedy  fur  children  under  the 
age  of  three  years,  for  all  sect)ndary  pleurisies,  and  for  all  cachectic  cases. 
Benefit  results  from  continuino;  the  use  of  dio-italis  in  the  stajie  of  exu- 
dation  Avhen  aconite  would  be  inadmissible.  A  child  of  two  years  can 
take  two  drops  of  the  officinal  tincture,  and  one  of  five  years  four  drops 
every  two  or  three  hours. 

Antipyrin  is  the  most  effectual  antipyretic  ■which  we  possess.  One 
or  two  doses  reduce  temperature  two  or  three  degrees.  It  therefore 
])romises  to  be  a  useful  remedy  in  the  first  stage  of  pleuritis  as  Avell  as 
in  other  acute  diseases,  when  the  temperature  is  so  high  as  to  involve 
danger.  It  is  not  a  tonic,  and  it  seems  to  impair  the  digestive  function. 
It  is,  therefore,  most  useful  in  those  diseases  which  are  not  attended  by 
any  marked  prostration,  but  in  wliicli  the  fever,  from  its  intensity, 
exhausts  the  strength.  If,  therefore,  in  the  commencement  of  pleuritis 
the  temperature  rises  above  103°,  it  may  properly  be  prescribed  in  doses 
of  four  grains  to  a  child  of  five  years,  and  be  repeated,  if  necessary,  in 
three  hours.  It  is  soluble  in  Avater,  and  it  may  be  employed  as  an 
enema  if  the  stomach  be  irritable. 

The  use  of  quinia  is  suggested,  since  it  is  an  antipyretic  and  tonic, 
but  in  my  practice  it  has  been  much  less  useful  in  pleuritis  than  in  pneu- 
monitis. This  agent,  in  whatever  form  given,  does  not  appear  to  exert 
any  notable  controlling  effect  either  on  the  fever  or  gravity  of  pleuritis. 
Nevertheless,  I  have  often  employed  it,  especially  in  secondary  pleuri- 
sies, with  or  without  digitalis,  and  it  probably  does  some  good  as  a  tonic. 
The  salts  of  quinia,  as  ordinarily  given  in  solution  to  young  children, 
are  frequently  vomited.  When  vomited,  a  solu])le  salt,  as  the  bisul- 
phate,  may  be  given  as  a  suppository,  or  Squibb's  oleate  of  quinia 
may  be  employed  by  inunction.  I  should,  however,  add  that,  though  I 
have  used  inunctions  of  the  oleate  in  pleuritis  during  the  last  year,  ten 
grains  of  the  alkaloid,  at  a  time,  I  have  not  seen  any  marked  beneficial 
effect.  To  meet  the  second  indication  in  the  treatment  of  the  first  stage, 
namely,  to  relieve  the  pain  and  restlessness,  and  to  diminish  the  cough, 
so  that  there  is  less  friction  of  the  pleural  surfaces,  our  chief  reliance 
must  be  on  hyoscyamus  or  one  of  the  opiate  preparations.  The  follow- 
ing formulpe  will  be  found  useful : 

li. — Titict.  opii  Jeodorat.  .         .  gtt.  xx. 

Tinc't.  diiritalis   ....  gtt.  xl. 

Syr.  pruni  Virginiani  .  .  2J. 

Aqiue  .....  5Jss. — Misce. 

Dose,  ono  teaspoonful  (one  drachm)  every  three  liours  for  an  infant  of  eighteen 
months.  The  tincture  of  hyoscyamus  may  be  employed  in  phice  of  the  opiate  ia 
double  the  dose. 

For  a  child  of  three  years : 

R. — Tinct.  ipecac,  comp.  1 

(Squibb's  liquid  Dover's  powder),  I  ;'iu  gtt   xxxij. 
Tinct.  diiriialis,  ) 

Syr.  pruni  Virgiiiiiuii         .         .      5  ij — Misce. 
Dose,  one  teaspoonful  every  two  or  three  hours. 


T  R  E  A  T  ^r  E  X  T  .  649 

For  a  robust  child  of  eight  years  Avith  primary  pleuritis : 

R. — Morph.  sulphat.        .         .         .         .         .     gr.  j. 

Tine.  rad.  aconit jrtt.  xx. 

Syr.  pruni  Yirginiarii      ....      5ij-s. — Misce. 
Dose,  one  teaspoonful  every  three  Lours. 

The  diet  in  the  first  stage  should  consist  of  milk  and  farinaceous  food, 
given  liberally.  The  meat-teas  or  the  expressed  juice  of  meat  may  be 
added,  and  in  secondary  pleurisies,  as  after  scarlet  fever,  it  is  often 
proper  to  give  a  moderate  amount  of  alcoholic  stimulants  from  the  fir.-<t. 

Second  Staf/e. — Measures  employed  in  the  first  stage  have  been  de- 
signed to  diminish  the  inflammation  and  relieve  suffering.  The  duty 
of  the  physician,  in  the  treatment  of  the  second  stage,  is  chiefly  to  aid 
in  the  removal  of  the  inflammatory  product,  and  prevent,  so  far  as  possi- 
ble, its  further  formation.  If  this  be  sero-fibrinous,  and  its  quantity  be 
small,  so  as  to  fill  only  the  lower  portion  of  the  cavity,  little  aid  may  be 
needed  from  therapeutics ;  but  a  larger  effusion,  compressing  the  lung 
and  displacing  the  heart,  requires  medicinal  and  often  surgical  measures. 
The  recommendations  of  Niemeyer,  that  the  patient's  food  contain  little 
liquid,  and  that  his  drinks  be  restricted,  as  a  means  of  increasing  ab- 
sorption from  the  pleural  surface,  is  not  applicable  to  young  children, 
whose  diet  must  of  necessity  be  largely  liquid,  and  that  of  infants  chiefly 
milk. 

Attempts  to  stimulate  the  ab.sorbents  by  external  treatment  of  the 
chest  are  of  doubtful  efficacy,  whether  by  the  application  of  the  so-called 
small  flying-blisters,  the  iodine  ointment  or  tincture,  or  a  stimulating 
linirnent.  The  common  practice  of  treating  glandular  swellings  by 
iodine  applications  suggests  tbeir  u.se  for  pleuritic  eff"usions,  and  of  the 
agents  employed  locally  to  hasten  absorption  they  are  probably  the  best, 
but  they  should  not  be  used  so  often  or  in  such  quantity  as  to  cause  pain 
or  restlessness  from  their  irritating  cff"ect. 

It  is  an  establi.slied  principle  in  therapeutics  that  the  removal  of  a 
serous  li(juid  in  either  of  the  larger  cavities  of  the  body  is  hastened  by 
such  remedies  as  produce  an  abundant  liquid  secretion  or  transudation 
from  any  of  the  organs  or  surfaces.  Hence  in  the  treatment  of  ])leuritic 
effusions,  those  medicines  which  act  on  the  skin  causing  diaphoresis, 
upon  the  intestines  causing  watery  stools,  and  upon  the  kidneys  causing 
diuresis,  are  at  once  suggested  as  most  likely  to  be  efficacious.  But 
sudorifics,  though  useful  for  dropsies  having  a  renal  origin,  have  not 
been  much  used  of  late  years  f  )r  the  removal  of  exudations  in  the  ]»leural 
cavity,  experience  having  siiown  tliat  they  arc  inadecjuate  for  this  pur- 
pose. Recently,  however,  the  discovery  of  a  very  active  agent  of  this 
class,  jaborandi,  has  revived,  in  a  measure,  the  sudorific  treatment  of  the 
second  stage,  so  that  in  the  National  Dispensatory  of  Stille  and  Maisch 
this  (liaj)horetic  is  one  of  the  recommcndefl  remedies.  But  the  heart, 
crippled  in  its  action  by  the  pressure  of  the  li(juid,  badly  tolei-ates  agents 
of  a  depressing  nature,  and  jaborandi,  or  its  active  princij)lo  piloearpin. 
exerts  a  weakening  effect  on  this  organ.  It  therefore  should  be  used 
with  caution  in  this  disea.se.  It  is  probably  best,  in  most  instances,  not 
to  employ  it,  inasmuch  as  we  possess  other  and  efficient  remedies. 


650  PLEURITIS. 

The  fact  that  sero-fibrinous  exudations  have  been  kno\Yn  to  diminish 
rapidly  during  attacks  of  diarrhoea  suggests  the  use  of  purgatives  ;  but, 
ahhough  an  open  state  of  the  bowels,  as  two  or  three  daily  stools,  aids 
in  absorption,  free  purgation  is  badly  borne  by  young  or  feeble  children, 
as  it  reduces  the  strength,  and,  therefore,  is  not  to  be  recouunended  as  a 
thera])eutic  measure.  Moreover,  there  is  not  the  need  of  employing 
severe  or  exhausting  medicines  for  the  removal  of  the  liquitl,  which 
existed  in  former  times,  since  we  are  able  to  accomplish  this  quickly, 
easily,  and  safely  by  the  excellent  aspirating  instruments  now  in  common 
use. 

Diuretics,  on  the  other  hand,  are  apparently  more  useful  while  they 
are  less  exhausting,  than  sudorifies  or  cathartics.  Digitalis,  combined 
Avith  the  citrate  or  acetate  of  potassium,  has  stood  the  test  of  experience, 
and  is  now  more  widely  used  than  any  other  agent  of  this  class.  Being 
both  a  diuretic  and  heart  tonic,  it  possesses  properties  which  render  it 
especially  serviceable  in  the  treatment  of  pleuritic  effusions.  The  fol- 
lowing is  a  useful  prescription  for  a  child  of  five  years  : 

R. — Piitiissii  iicetatis gij. 

Infus.  digitalis 3iij. — Misce. 

Give  one  teaspoonful  every  three  liouri. 

It  is  a  matter  of  observation  that  absorption  occurs  more  rapidly,  and 
a  sero-fibrinous  is  less  likely  to  become  a  purulent  effusion,  if  the  bodily 
condition  be  good.  Hence  tonics,  especially  the  bitter  vegetables,  are 
sometimes  useful,  and  a  diuretic  in  combination  Avith  a  tonic,  as  tbe 
acetate  of  potassium  in  decoction  of  cinchona,  may  often  be  prescribed 
with  advantage. 

Still,  however  judicious  the  treatment,  hygienic  and  medicinal,  many 
cases  recpiire  surgical  interference,  and  the  number  of  such  is  larger  in 
the  city  than  in  the  country,  and  in  tenement-houses  than  in  the  better 
walks  of  life,  since  the  cachexia  so  common  in  city  children  increases 
the  liability  to  purulent  exudations. 

Thoracentesis. — The  indications  for  the  operation  are  the  following : 

1st.  Dyspnrea  due  to  the  presence  of  the  liquid,  Avhether  it  be  sero- 
fibrinous, purulent,  or  hemorrhagic.  Usually  when  dyspn(ea  occurs,  the 
pleural  cavit}'-  is  full,  but  if  there  be  parenchymatous  disease  of  either 
lung,  a  moderate  quantity  of  li(juid  may  cause  such  embarrassment  of 
respiration  that  thoracentesis  is  indicated. 

2d.  A  flat  percussion  sound  over  the  entire  affected  side,  with  dis- 
placement of  the  heart,  even  if  there  be  no  present  dyspnoea,  is  also  an 
indication  for  the  operation,  for  dyspnoea  may  occur  suddenly  with 
other  alarming  symptoms  between  the  visits  of  the  physician.  More- 
over, experience  has  shown  that  absorption  from  a  distended  pleural 
cavity  is  very  tardy,  in  consequence  of  compression  of  the  absorbents, 
whereas,  if  a  portion  of  the  liquid  be  removed,  absorption  of  the  re- 
mainder is  more  rapid.  The  patient  with  full  pleural  cavity  and  lung 
totally  compressed  lies  on  the  affected  side,  and  is  usually  unconrfort- 
able  in  any  other  position,  and  the  Avithdi-awal  of  a  portion  of  the 
liquid,  as,  for  exam|)le,  one  half,  the  openition  being  discontinued  when 
the  patient  begins  to  cough  or  evince  distress,  produces  no  ill-effect,  and 
increases  the  comfort. 


TEEATMEXT.  651 

3d.  A  moderate  effusion,  without  material  decrease  in  quantity  after 
some  weeks  of  observation,  also  indicates  the  need  of  surgical  interfer- 
ence, since  long  compression  of  a  lung  involves  risks.  There  is  danger 
that  catarrhal  ending  in  cheesy  pneumonia  and  tubercles  may  occur  in 
a  lung  whose  function  is  long  suspended ;  besides  the  longer  compres- 
sion has  existed,  the  more  tardy,  diflBcult,  and  incomplete  will  be  the 
inflation  when  the  liquid  is  removed,  on  account  of  the  altered  state  of 
the  alveoli,  and  the  presence  of  fibrinous  bands  over  the  lung.  Thus, 
in  a  case  recently  under  observation,  only  partial  inflation  of  the  lung 
occurred,  after  letting  out  the  liquid,  so  that  the  ribs  and  shoulder  on 
the  affected  side  are  permanently  depressed,  and  unequivocal  symptoms 
of  tuberculosis  are  now  present. 

4th.  If  the  inflammation  extend  to  the  pericardium,  so  as  to  cripple 
the  heart's  action,  or  if  there  be  any  serious  preexisting  heart  disease, 
the  liquid,  even  in  moderate  quantity,  may,  by  pressure,  so  embarrass 
and  retard  the  hearts  action  that  its  cavities  are  not  properly  filled,  so 
that  passive  congestion  of  certain  organs,  and  dangerous  amiemia  of 
others,  especially  of  the  brain,  may  result.  Under  such  circumstances, 
an  early  performance  of  thoracentesis  is  indicated. 

5th.  Empyema. — The  presence  of  pus  in  the  pleural  cavity  affords 
in  itself,  in  a  large  proportion  of  cases,  sufficient  indication  of  the  need 
of  thoracentesis.  In  recent  cases,  with  only  moderate  constitutional 
disturbance  and  embarrassment  of  respiration,  if  we  ascertain  by  the 
hypodermic  syringe  that  the  liquid  is  only  slightly  clouded  by  leuco- 
cytes, surgical  interference  may  be  postponed,  'while  the  acute  inflam- 
mation is  treated.  Thus,  in  case  of  an  infant  of  two  months,  thin  pus 
was  withdrawn  on  the  fourth  day  of  acute  pleuritis,  and,  although 
thoracentesis  was  early  performed,  it  aj)peared  probable,  from  the 
subsequent  course  of  the  case,  that  it  would  have  been  as  well  had  the 
operation  been  deferred.  If  spontaneous  evacuations  of  pus  have 
occurred  through  one  of  the  intercostal  spaces,  producing  a  fistula,  from 
which  there  is  a  daily  oozing,  or  if  it  be  probable,  from  the  symptoms 
and  signs,  that  pus  is  escaping  from  the  jjleural  cavity  into  a  bronchial 
tube,  and  is  being  gradually  ex])ectorate<l — a  mode  of  cure  which,  as  1 
have  elsewhere  stated,  is  not  infrequent  in  children — thoracentesis  may 
be  deferred.  In  the  case  of  an  infant,  aged  six  months,  recently  under 
treatment  for  empyema  of  the  left  side,  avo  removed  four  ounces  of  pus, 
and  washed  out  the  pleural  cavity.  The  opening  having  closed,  and 
the  physical  signs  indicating  the  reaccuumlation  of  a  considerable  quan- 
tity of  li([uid,  we  were  ])reparing  for  a  second  operation,  when  the 
parents  and  nurse  called  our  attention  to  the  fact  that  there  were  occa- 
sional severe  attacks  of  coughing,  during  Avhich  the  breath  presented  a 
very  decidedly  purulent  odor.  Although  there  was  no  external  expec- 
toration, as  the  sputum  was  swallowed,  thoracentesis  was  postponed, 
and  the  result  justified  the  decision,  for  the  patient  gradually  conva- 
lesced. Excei)t  under  circumstances  like  the  above,  empyema,  when 
clearly  diagnosticated,  by  the  employment  of  the  hypodermic  syringe, 
should  be  promptly  treated  by  evacuation  of  the  pus. 

InsfruynenfK  to  he  Laed,  and  Mode  of  Operatinr/. — Ingenious  instru- 
ments tor  tapping  the  chest  have  been  invented  by  Dr.  Chadbournc,  of 


652  PLEURITIS. 

the  New  York  Foundling  Asylum,  Dr.  A.  M.  Phelps,  of  Chateauga-v, 
Franklin  Co.,  N.  Y.,  and  others,  which,  by  India-rubber  packing,  totally 
exclude  air,  while  the  operation  is  perforniod  with  focility  and  little 
pain.  That  devised  by  Dr.  Chadbourne  has  a  canula  with  two  arms, 
one  for  attachment  })y  means  of  tubing,  to  the  exhausting  ivceiver,  and 
the  other  is  designed  to  facilitate  irrigation  of  the  })leural  cavity. 

Phelps's  apparatus  has  a  third  tube,  entering  the  bottle  through  the 
stopple,  and  a  glass  tube  passes  from  the  stopple  to  nearly  the  bottom 
of  the  bottle.  With  this  apparatus,  by  reversing  the  movement  of  the 
syringe,  the  liquid  can  be  withdrawn  from  the  chest,  the  bottle  emptied 
of  it,  the  water  used  for  irrigation  lie  conveyed  into  the  bottle,  from,  the 
bottle  to  the  chest,  and  back  into  the  bottle,  Avithout  changing  the  ])Osi- 
tion  of  the  bottle  or  removing  the  stopple.  I  would  suggest  the  use  of 
the  trocar  and  canula  instead  of  the  sliding  aspirator  point  which  plays 
outside  the  canula,  as  an  improvement  in  this  instrument. 

The  instrument  which  I  have  been  in  the  habit  of  emjdoying  is  of 
simpler  construction.  The  canula  has  about  the  size  of  the  smallest 
needle  of  Dieulafoy's  aspirator;  the  proper  size,  in  my  opinion,  for 
thoracentesis,  for  both  sero-fibrinous  and  purulent  exudations.  I  greatly 
prefer  the  use  of  the  exhausting-bottle  rather  than  the  exhausting-pump 
Avithout  the  bottle,  as  it  is  more  convenient  and  produces  greater  suc- 
tion, from  its  greater  size.  The  canula  is  provided  with  an  arm,  which 
connects  it  by  tubing  with  the  exhausting-bottle.  Beyond  this  arm, 
the  body  of  the  canula,  sufficiently  expanded  to  contain  India-rubber 
packing,  extends  about  one  and  one-half  inches,  and  is  ])rovided  with  a 
stopcock.  Through  this  packing  the  trocar  is  introduced,  and,  after 
the  puncture,  it  is  Avithdrawn  to  the  stopcock,  Avhich  is  then  turned  to 
prevent  the  admission  of  air.  Then  the  obturator  is  mtroduced  in  place 
of  tlie  trocar,  so  as  to  remove  any  obstruction  Avhich  may  enter  the 
canula. 

The  tubing  Avhich  extends  from  the  arm  of  the  canula  to  the  bottle 
should  be  firm,  Avith  a  someAvhat  larger  bore  than  that  of  the  canula, 
and  its  point  of  attachment  to  the  bottle  should  also  be  provided  Avith  a 
stopcock.  A  short  glass  tube  introduced  into  this  tubing  near  the 
canula  is  convenient  for  noticing  the  character  of  the  fluid,  Avhich,  if  it 
be  thick  pus,  may  flow  Avith  difficulty,  and  not  reach  the  bottle.  A 
bottle  of  sufficient  capacity  to  hold  two  quarts  obviously  produces  more 
suction  poAver  than  one  of  less  size,  and  is,  therefore,  preferable  for  cer- 
tain cases,  and  its  sides  should  be  marked  to  indicate  ounces  and  drachms. 
The  tube  Avhich  connects  the  canula  Avith  the  bottle  enters  through  the 
stopple,  and  proceeding  from  the  stopple  is  another  tube  similar  to  the 
first,  to  Avhich  the  syringe  is  attached.  The  syringe  has  two  points  for 
attachment  to  the  tube,  and  a  double  action  in  its  interior,  so  that  at- 
tached by  one  point  it  exhausts  the  air  from  the  bottle,  and  attached  by 
the  other  point  it  condenses  air  in  the  bottle.  The  stopcock  between 
the  canula  and  the  bottle  should  ahvays  be  closed  Avhen  the  syringe  is 
used,  Avhether  for  exhaustion  or  condensing.  It  is  very  important  that 
this  should  be  constantly  borne  in  mind  Avhen  Avorking  the  syringe,  or 
air  may  be  throAvn  into  the  pleural  cavity  and  much  harm  done. 

Mode  of  Operating  for  Sero-fibrinous  Exudations. — In  the  following 


TREATMENT.  653 

remarks  I  shall  state  what  I  consider  the  best  method  for  performing 
thoracentesis,  having  fonned  my  opinion  from  the  cases  Avhich  I  have 
witnessed  and  been  able  to  follow,  in  institutions  and  in  family  prac- 
tice. A  mode  of  treatment  which  may  be  safe  and  proper  for  the  ailult 
is  not  always  the  best  for  the  child,  and,  as  there  are  different  opinions 
and  different  modes  of  procedure,  and  as  many  who  are  familiar  with 
adult  cases  recommend  similar  treatment  for  the  child  to  that  Avhicli 
they  have  emploved  with  success  for  the  older  and  more  robust  cases,  I 
shall  advise  the  abandonment  of  certain  measures  which  are  in  common 
use,  and  the  substitution  of  others.  The  hypodermic  syringe  should  be 
first  introduced  at  the  point  Avhere  it  is  proposed  to  perform  the  opera- 
tion, the  needle  being  inserted  about  one  inch,  for  I  hold  it  unjustifiable 
to  tap  the  chest  without  first  ascertaining  that  there  are  no  adhesions  at 
the  site  selected  for  puncture,  and  at  the  same  time  ascertaining  the 
character  of  the  liipiid.  Incision  of  the  skin  Avith  the  knife  and  spray- 
ing the  surface  with  ether  are  not  required  as  preliminary  treatment, 
since  the  puncture  is  quickly  and  easily  performed  with  a  small  trocar, 
and  with  very  little  pain.  The  rule  is  established  by  many  observa- 
tions that  the  operation  should  be  performed  in  or  near  the  vertical  line 
passing  through  the  angle. of  the  scapula,  and  between  the  eighth  or 
ninth  ribs,  or  one  of  the  adjacent  intercostal  spaces.  I  have  elsewhere 
stated  that  a  point  a  little  external  to  this  line  is  preferable,  as  the  lung 
is  less  liable  to  be  injured.  The  instrument  should  obviously  be  inserted 
no  farther  than  will  be  sufficient  to  reach  the  liquid,  and,  since  from 
measurements  which  I  have  made,  the  thickness  of  the  thoracic  wall  in 
rather  fieshy  children  is  about  half  an  inch,  penetration  to  the  depth  of 
one  inch  will  ordinarily  be  sufficient  to  pass  the  fibrinous  layer.  We 
are  liable  to  puncture  more  deeply  than  is  necessary  without  some  safe- 
guard, and  incur  the  risk  of  wounding  the  lung.  India-rubber  tubing 
may  cover  the  instrument  to  within  one  inch  of  the  end,  or  a  cord  may 
be  tied  snugly  around  the  instrument  at  one  inch  from  the  tip.  The 
sensation  communicated  to  the  fingers  will,  however,  be  the  best  guide 
to  the  careful  operator  as  regards  the  exact  depth  to  which  the  instru- 
ment should  be  carried.  The  trocar  shouhl  now  be  withdrawn,  the  ob- 
turator introduced  in  its  place,  the  air  exhausted  from  the  bottle,  and 
then  the  stopcock  turned,  to  allow  the  liquid  to  escape. 

It  should  How  slowly,  as  it  probably  will,  through  so  small  a  canula, 
but  the  flow  can  be  regulated  by  the  stopcock.  The  quantity  to  be  re- 
moved depends  upon  the  age  and  condition  of  the  child,  the  size  of  the 
cavity,  and  the  quantity  of  the  li([uid,  but  if  the  patient  begin  to  cough 
or  feel  uncomfortable  after  the  removal  of  one-half,  or  even  one-third  of 
the  li((uid,  the  canula  should  be  withdrawn.  The  sensation  of  insuffi- 
cient breath  is  no  longer  experienced,  and  the  remaining  li((uid  is  ])ro- 
gressively  absorbed.  This  operation  is  one  of  the  easiest  in  surgery, 
while,  witli  the  precautions  mentioned  above,  no  ill  efU'ect  need  l)e  ap- 
prehended. One  operation  is.  in  most  instances,  all  that  is  re((uired, 
though,  if  need  be,  it  can  be  relocated  after  some  days,  and  it  is  very 
seldom  that  the  lung  does  not  fully  expand  to  fill  the  chest  if  the  opera- 
tion 1)0  ])crfonned  at  the  ]u-oper  time. 

Mode  of  OjjeratiiKj  for  Enipyaina. — It  will  aid  in  understanding  this 


654  P  L  E  U  R  I  T I  S  . 

part  of  our  subject  to  remember  that  all  pleuritic  exudations  contain 
pus-cells,  and  that  the  only  anatomical  difference  between  sero-fibrinous 
exudations  and  empyema  is  in  the  proportion  of  these  cell*.  There  is, 
therefore,  no  fixed  and  definite  boundary  line  between  the  two  kinds  of 
exudation.  Tlie  term  empyema  is,  as  all  know,  applied  by  common 
usage  to  the  liquid  when  it  contains  so  many  leucocytes  or  pus-cells  that 
a  turbid  appearance  is  imi)arted  to  it.  Absorption  is  slow  and  difficult. 
or  impossible,  if  the  liipiid  contain  a  large  amount  of  solid  ingredients, 
to  wit,  fibrin  and  pus-cells,  while  liquid  containing  only  a  small  pro- 
portion of  these  constituents  more  readily  enters  the  absorbents.  In 
other  Avords,  thin  pus  may  be  absorbed  and  removed  from  the  system 
by  natural  methods,  or  by  the  same  instrument  and  operation  which  we 
have  reconnnended  for  sero-fibrinous  exudations,  Avhile  a  thick  li(i[uid  ad- 
herent to  the  pleura,  or  sinking  heavily  in  dependent  portions  of  the 
cavity,  disappears  very  slowly,  losing  by  absorption  only  a  little  of  the 
liquor  puris,  while  the  bulk  of  it  cannot  be  absorbed,  so  that  the  only 
relief  is  by  evacuation  through  an  opening.  Often  in  ])ractice,  after  the 
acute  symptoms  of  an  empyema  have  in  a  measure  abated,  the  physical 
signs  indicate  some  diminution  of  the  licpiid  in  successive  weeks,  but 
further  removal  soon  comes  to  a  standstill,  and  the  resources  of  surgery 
must  be  tried. 

The  same  small  trocar  and  cnnula,  or  a  little  larger,  should  be  used  for 
tapping  the  chest  of  an  emjiyemic  child  which  Ave  have  recommended 
for  sero-fibrinous  exud;ition,  and  with  the  same  precautions.  If  the 
liquid  be  thin  and  but  slightly  turbid,  if  it  be  but  little  removed  from 
sero-fibrin  in  its  character,  it  will  flow  through  the  canula,  even  if  it  be 
necessary  to  use  the  obturator  often  to  remove  obstructions.  Having 
withdrawn  all  the  liquid  Avhich  Avill  floAV  through  the  opening,  unless 
severe  coughing  or  some  unj)leasant  symptom  occur,  Avliich  is  an  indica- 
tion to  discontinue  the  Avithdrawal,  the  instrument  is  removed,  and  the 
aperture  may  be  closed  Avith  adhesive  plaster.  In  exceptional  instances 
one  operation  is  sufficient  to  effect  a  cure,  though  convalescence  in  em- 
pyema is  tardy  under  the  most  favorable  circumstances.  If  we  observe 
from  Aveek  to  Aveek  some  return  of  appetite,  more  cheerfulness  and  sleep, 
easier  breathino;,  and  less  frequent  couoli,  the  case  can  be  left  to  hvorienic 
management  and  restorative  medicines.  If,  as  is  probable,  the  improve- 
ment be  only  temporary,  and  after  some  days  examination  shoAv  that 
the  liquid  has  reaccumulated  to  nearly  or  quite  its  former  quantity,  and 
symptoms  occur  Avliich  indicate  the  need  of  surgical  interference,  the 
operation  should  be  repeated.  The  use  of  a  small  trocar  produces  no 
shock  or  prostration,  and  very  little  more  pain  tlian  occurs  from  the 
hypodermic  injection  of  medicine. 

It  seems  to  be  a  belief  in  the  profession  that  pus  in  the  ])leural  cavity 
should  be  evacuated  as  soon  as  discovered,  Avithout  regard  to  the  dura- 
tion of  the  pleurisy,  or  the  amount  of  distention  and  pressure.  But  in 
cases  of  its  early  eA^acuation — as,  for  example,  Avhcn  the  inflammation 
has  continued  two  Aveeks — patients  have  not  in  my  practice  done  so  well 
as  Avhen  ten  or  tAvelve  Aveeks  have  elapsed  and  the  jjleural  surface  has 
become  thickened  and  less  vascular. 

In  most  cases  the  pleural  cavity  refills  Avith  pus  in  a  few  Aveeks  after 


TREATMENT.  655 

aspiration,  and  the  operation  is  again  required.  After  three  or  four 
aspirations,  if  the  secretion  of  pus  do  not  appear  to  diminish,  a  free 
incision  should  he  made  with  the  knife  at  the  same  point  as  that 
selected  for  aspiration — that  is,  hetween  the  eighth  and  ninth  ribs,  and 
in  the  line  passing  perpendicularly  through  the  lower  angle  of  the 
scapula.  An  incision  should  be  made  with  a  sharp-pointed  bistoury 
a  little  nearer  the  ninth  than  the  eighth  rib,  sufficiently  large  to  admit 
the  blunt-pointed  bistoury,  and  with  this  the  incision  should  be  ex- 
tended to  the  distance  of  one-third  to  one-half  inch,  which  will  allow 
the  pus  to  flow  out  freely.  The  opening  should  then  be  covered  by 
oakum  confined  by  long  strips  of  adhesive  plaster.  Pus  may  or  may 
not  continue  to  flow  into  the  oakum.  If  it  do  not  the  opening  will 
close,  if  left  to  itself,  within  two  or  three  days.  No  tent  or  drainage- 
tube  is  employed,  for  reasons  to  be  mentioned  hereafter.  The  physi- 
cian should  return  after  twelve  or  twenty-four  hours,  not  later,  and 
should  introduce  through  the  opening  the  ordinary  gum-elastic  male 
catheter,  warmed  so  as  to  be  flexil)le,  and  strongly  bent  at  its  middle. 
The  point  should  be  directed  to  the  bottom  of  the  cavity.  Perhaps  the 
soft  rubber  catheter  might  be  preferable,  but  I  have  never  used  it,  being 
satisfied  with  the  other.  The  catheter  should  be  attached  by  tubing  to 
the  exhausting-syringe  or  bottle,  and  any  pus  in  the  depending  ])ortions 
of  tlie  cavity  will  be  readily  removed.  I  have  generally,  at  this  visit, 
removed  from  the  bottom  of  the  cavity  two  or  three  ounces,  sometimes 
very  thick,  and  such  as  would  not  readily  flow  from  the  opening.  Every 
day  or  twice  daily  the  operation  should  be  repeated,  which  Avill,  I  think, 
more  effectually  remove  the  pus  than  washing  out  the  cavity,  and  the 
opening  cannot  close.  This  operation  detains  the  physician  only  a  few 
moments.  The  catheter  should  be  a  No.  X.,  and  it  is  the  best  possible 
probe.     By  the  close  of  the  first  week  the  o])ening  becomes  fistulous. 

After  each  removal  of  the  pus,  long  strips  of  adhesive  plaster  firmly 
applied  over  the  ribs,  from  the  sternal  region  downward  and  backward, 
facilitate  approximation  of  the  pleural  surfaces  and  obliteration  of  the 
cavity.  During  convalescence,  the  patient,  if  old  enough,  should  be 
directed  to  make  fidl  inspirations,  which  serve  to  expand  the  lungs. 

That  so  sim})le  and  important  an  oj)eration  as  thoracentesis  should  have 
been  known  and  practised  by  the  ancients,  even,  it  is  said,  by  Hippo- 
crates, and  have  fallen  into  disuse,  till  it  was  revived,  in  our  OAvn  times, 
by  Bowditch  and  Trousseau,  seems  remarkable.  This  was  probably  in 
part  due  to  the  bad  instruments  employed,  and  in  part  to  the  fact  that 
in  olden  times  the  operation  was  performed  in  the  anterior  walls  of  the 
chest,  where  adhesions  are  fix'quently  present.  But  there  are  certain 
accidents  and  unfavorable  results  of  the  operation  which  may  be  profit- 
ably considered,  since  they  can  nearly  always  be  avoided. 

1st.  The  Admission  of  Ah-  into  the  Pleural  Cavity. — This  is  un- 
necessary, and  can  be  avoided  ;  but  those  who  have  often  witnessed  the 
operation,  as  ordinarily  performed,  have  remarked  the  fact  that  the  ad- 
mission of  more  or  less  air  is  common. 

The  entrance  of  a  certain  amount  of  air  into  a  serous  cavity,  when 
the  serous  membrane  is  in  its  normal  state,  does  not  appear  to  be  ])ro- 
ductive  of  harm  with   ordinary  precautions,  as   regards  temperature. 


656  PLEURITIS. 

etc.,  as  in  ovariotomy,  in  which  air  is  admitted  into  the  laro;cst  serous 
cavity  in  the  body;  and  the  moderate  admission  of  air  into  the  pleural 
cavity,  Avlien  tlie  pleura  is  healthy,  does  not,  as  a  rule,  ])ro(luce  any  ill 
eftcct.  1'lius  a  case  is  related  of  a  man  who  suffered  from  heart  disease, 
and  was  led  to  think  that  the  pressure  of  a  small  amount  of  air  inter- 
nally miu'ht  be  sul)stituted  for  external  pressure,  which  always  gave 
relief.'  He  was  his  own  instrument-maker  and  o])erat(>r.  He  con- 
structed a  small  tube  about  as  slender  as  a  common  pin,  to  which  a 
bladder  was  attached  filk'd  with  air.  The  point  of  this  was  thrust 
throuirh  an  intei'costal  space  till  it  penetrated  the  pleural  cavity,  and 
air  was  made  to  enter  by  compressing  the  bladder.  Kelief  always 
followed,  ami  the  patient's  health  improved.  Tliis  treatment  was  con- 
tinued two  or  three  years.  Dr.  Lizars,  Avho  was  present  at  the  meeting 
of  the  Medical  Society  before  which  this  case  was  related,  stated  that 
he  had  performed  a  similar  operation  on  four  or  five  patients  affected 
with  aneurisms,  with  some  ap])arent  benefit,  and  in  no  case  with  injury. 

But  the  condition  is  very  different  if  there  be  intiammatory  products 
in  the  cavity.  It  is  a  fact  known  to  all  observers  that  animal  liquids 
withdrawn  from  the  circulation,  and  escaped  from  the  vessels  through 
injury  or  disease,  remain  in  a  closed  cavity  for  a  lengthened  period 
without  putrefactive  change,  as  for  example  a  clot  of  blood  under  the 
scalp  or  pericranium  of  a  newborn  infant;  but  if  air  be  admitted,  it  be- 
comes offensive  within  a  few  hours.  The  admission  of  air  into  the 
pleural  cavity  which  contains  exuded  products  undoubtedly  promotes 
putrefactive  changes  in  the  latter,  and  the  admission  of  even  a  small 
amount  of  air,  containing,  as  it  does,  microorganisms,  which  multiply 
rapidly  in  the  animal  fluids,  and  which  appear  to  be  the  active  agents 
in  putrefaction,  suffices  to  convert  sero-fibrin,  or  laudable  pus,  into  an 
offensive,  irritating,  and  poisonous  liquid,  which  increases  the  constitu- 
tional disturbance  and  the  gravity  of  the  disease. 

Air  in  the  pleural  cavity,  in  proportion  to  its  quantity,  also  tends  to 
prevent  the  approximation  to  each  other  of  the  pleural  surfaces  and  the 
obliteration  of  the  cavity,  which  is  required  in  all  empyemic  cases,  since 
it  is  the  mode  of  cure.  Obviously  the  entrance  of  air  does  less  harm  if 
there  be  a  fistulous  opening  and  pus  escajie  as  soon  as  it  forms,  than  in 
a  closed  cavity,  but  it  should,  in  all  instances,  be  avoided,  as  never 
beneficial,  and  likely  to  do  harm  in  the  manner  indicated.  It  is  never 
a  necessary  accident  of  thoracentesis,  since  it  can  be  avoided  by  the  use 
of  proper  instruments  provided  with  India-rubber  packing  and  stop- 
cocks. There  can  be  no  doubt,  also,  that  the  point  of  the  aspirator  has 
often  so  pricked  and  torn  the  lung,  that  air  has  entered  the  cavity  from 
this  organ — a  result  avoided  by  judiciously  using  the  trocar  and  canula. 

2d.  The  lung  is  sometimes  injured  by  the  point  of  the  hypodermic 
needle,  employed  for  diagnosis.  Cases  are  recorded  in  the  hospitals  of 
New  York,  of  the  breakino;  off  and  loss  of  the  needle  in  the  limg,  from 
sudden  and  strong  movement  of  this  organ,  as  in  coughing.  The  most 
severe  injury  is,  however,  commonly  produced  by  the  aspirator  needle, 
and  some  very  serious  cases  of  this  accident  have  occurred,  in  Avhich  the 

'  London  Lancet,  January  15,  1831. 


TREATMENT.  657 

needle  so  pierced  and  tore  the  lung  that  not  only  air  escaped  from  it, 
but  also  a  considerable  quantity  of  blood.  It  is  obvious  that  the  danger 
of  injuring  the  lung  is  greater  in  recent  than  in  chronic  cases,  and 
greater  in  sero-fibrinous  than  in  purulent  pleuritis,  for  a  thickened,  in- 
filtrated, and  firm  pleura  affords  protection  to  the  lung.  It  is  very 
difficult  to  avoid  injuring  this  organ  if  suction  be  made  and  the  liquid 
be  withdrawn  with  the  unguarded  point  of  the  aspirator  needle  project- 
ing into  the  chest.  The  removal  of  the  li(piid  necessitates  the  imping- 
ing of  the  lung  upon  the  point  of  the  instrument  even  if  it  be  held  very 
obliquely,  and  in  recent  cases,  when  there  is  little  thickening  and  infil- 
tration of  the  pleura,  the  surface  of  this  organ  may  be  pricked  or  torn 
sufficiently  to  allow  air  to  escape,  and  hemorrhage  occur,  when  the  oper- 
ator who  holds  the  needle  can  scarcely  believe  that  such  an  accident 
were  possible,  so  slight  has  been  the  sensation  communicated  to  the 
fingers.  Thus  thoracentesis  was  performed  on  an  infi\nt  of  two  months 
who  had  severe  empyema  of  short  duration.  The  instrument  Avas  held 
by  myself  obliquely,  and  it  entered  the  pleural  cavity  only  a  short  dis- 
tance, and  yet  the  lung  was  injured  in  three  places,  from  Avhich  it  was 
probable,  from  the  signs  and  symptoms,  that  air  had  escaped.  The 
specimen  showing  the  injury  Avas  exhibited  to  the  Patliological  Society 
in  IHTD.  Obviously,  to  prevent  this  injur}',  aspiration  should  be  per- 
formed through  the  covered  needle,  as  that  of  Phelps,  or  Potain's,  or, 
which  I  have  recommended  above,  and  pi'efer,  the  trocar.  I  must  here 
repeat  what  has  been  stated  above,  not  to  plunge  the  trocar  to  a  greater 
depth  than  is  needed,  which  is  about  one  inch.'  The  end  of  the  canula 
may  also  injure  the  lung  if  it  be  pressed  in  too  deeply,  since  it  is  neces- 
sarily rather  sharp  from  its  small  size. 

3d.  Wasliing  out  the  Pleural  Cavity. — Since  the  aspirator  has  come 
into  general  use,  it  is  the  common  practice  to  wash  out  the  pleural 
cavity  with  carbolized  water  in  the  treatment  of  empyema.  The  pro- 
portion of  carbolic  acid  to  Avater  commoidy  employed  is  about  one  part 
to  eighty,  and  at  a  temperature  of  100°.  From  a  discussion  at  the 
meeting  of  the  New  York  Surgical  Society,  Oct.  12,  1880,  it  appears 
that  the  use  of  carbolized  water  involves  risk  of  carbolic  acid  poisoning 
in  case  the  licpiid  be  only  partially  removed  after  it  is  thrown  into  the 
jileural  cavity,  and  the  late  Prof.  Erskinc  Mason  was  in  the  habit  of 
employing  salicylic  acid,  one  part  to  one  hundred  of  Avatcr,  in  place  of 
carbolic  acid,  since  it  possesses  all  the  advantages  Avith  none  of  the 
possible  risks  of  the  latter.  He  stated  that  it  promptly  deodoi-izcs  fetid 
pus  even  in  the  proportion  of  one  part  to  tAvo  hundred.  The  use  of  car- 
l)olic  acid  woidd  ])r(»bably  be  entirely  safe  if  the  liquid  Avere  removed 
immediately  after  Avashing  the  cavity,  but  for  some  reason  this  is  not 
always  j)()ssil)le.  In  case  of  an  infant  Avith  empyema  under  treatment 
by  I)rs.  LockroAv,  Plllington,  and  myself,  after  removing  the  pus  by 
trocar  and  canula  attached  to  the  exhausting-bottle,  and  once  Avashing 
out  the  pleural  cavity,  the  liquid  Avas  throAvn  in  a  second  time,  oiij  into 
the  left  ])l(Miral  cavity  of  an  infant  of  five  months,  but  not  a  drop  of  it 
could  be  removed,  Tliere  Avas,  hoAvever,  no  symptom  Avhich  Ave  could 
refer  to  the  carbolic  acid.      In   view  of  these  facts,  and  the  ))ossib]e 

•12 


658  PLEURITIS. 

danger  of  carbolic  acid  poisoning,  the  use  of  salicylic  acid  appears  to  be 
pi'eferable,  at  least  for  children,  who  are  less  able  to  resist  the  action  of 
poisonous  agents  than  adults. 

In  this  connection  I  must  state  my  conviction  that  washing  out  the 
pleural  cavity  is  unnecessary  if  empyema  be  treated  as  recommended 
above,  and  it  may  be  injurious.  But  it  is  proper  treatment  when  the 
pus  has  undergone  decomposition,  is  oifensive  to  the  smell,  and  therefore 
poisonous.  If  it  be  putrid,  its  immediate  disinfection  as  well  as  removal 
from  the  pleural  cavity  appears  to  be  clearly  indicated,  but  in  the  com- 
mon form  of  empyema,  as  the  pus  escapes  through  the  opening  which 
has  been  made,  and  tlie  suppurative  cavity  becomes  smaller,  adhesions 
of  the  pulmonary  and  costal  surfaces  occur,  Avhich  the  injection  of  water 
may  tear  up  and  destroy,  and  thus  the  obliteration  of  the  cavity  is 
retarded.  Letting  out  the  pus  and  approximation  to  each  other  of  the 
pleural  surfxces  are  the  indications  as  regards  surgical  measures.  Be- 
sides, washing  out  the  pleural  cavity  is  not  devoid  of  danger.  Alarming 
symptoms  may  be  developed  unexpectedly  and  rapidly,  even  when  the 
operation  is  slowly  and  cautiously  performed.  The  infant  of  five  months, 
with  empyema,  Avhose  case  I  have  alluded  to,  furnished  a  striking  ex- 
ample of  this.  Four  ounces  of  pus  had  been  removed  through  a  small 
canula  from  the  left  pleural  cavity,  and  without  removing  the  canula  the 
cavity  had  been  once  washed  out.  It  was  proposed  to  repeat  the  wash- 
ing, as  the  infant  had  thus  far  tolerated  the  operation,  and  was  in  an 
unusually  favorable  state  for  a  case  of  empyema.  The  patient  was  in  a 
semi-erect  position,  and  three  ounces  of  water  at  a  temperature  of  100° 
had  entered  the  cavity  from  the  inverted  bottle,  when  he  began  to 
cough,  fretted,  and  became  very  restless.  Immediately  Dr.  Loekrow 
applied  the  suction-point  of  the  syringe  to  the  tubing,  and  attempted  to 
withdraw  the  liquid,  but  with  no  result.  The  patient's  face  assumed  a 
deadly  pallor,  he  frothed  at  the  mouth,  his  lips  were  compressed,  and 
breatliing  ceased.  He  was  to  all  appearances  dead.  He  was  imme- 
diately placed  upon  the  back  by  Dr.  Billington,  and  by  prompt  resort 
to  artificial  respiration,  the  terrible  suspense  was  soon  ended  by  the 
gasps  of  the  child,  and  the  return  in  a  few  moments  of  consciousness 
and  normal  respiration.  It  seemed  to  me  that  this  untoward  accident 
was  due  to  the  flow  of  water  against  the  heart,  so  that  it  prevented  full 
dilatation  of  its  cavities,  and,  consequently,  diminished  the  flow  of 
blood  into  the  aorta  and  produced  amiemia  of  the  brain.  Lichtenstern 
says:  "Various  causes,  which  sometimes  quite  interrupt  or  impede  the 
flow  of  blood  to  the  left  heart,  such  as  severe  paroxysms  of  coughing, 
vomiting,  lifting  heavy  burdens,  may  give  rise  to  a  suddenly  fatal 
aniTemia  of  the  left  heart,  and  secondarily  of  the  brain.  The  anremia 
of  the  lungs  or  brain  found  in  many  cases  is  only  of  secondary  impor- 
tance. It  frequently  happens  after  thoracentesis  with  aspiration  that  an 
ansemia  is  produced  in  tlie  partially  distended  lung,  and  this  may  lead  to 
death  by  asphyxia.  In  sudden  death  during,  or  immediately,  or  a  short 
time  after  thoracentesis  by  aspiration,  the  cause  is  an.iemia  either  of  the 
heart  or  brain.  In  cases  in  which  severe  syncope  and  sudden  death  are 
observed  during  the  irrigation  of  the  pleural  cavity,  the  cause  is  cither 


TREATMENT.  659 

direct  mechanical  concussion  of  the  easily  exhausted  heart,  by  the  stream 
of  water  thrown  in,  or  shock."  ^ 

4th.  The  Use  of  Tent  and  Drainage  Tube  in  Emjjyema. — With  due 
regard  for  the  opinions  of  the  experienced  surgeons  who  employ  and  re- 
commend the  tent  and  drainage  tube,  but  whose  observations  have  been 
largely  upon  adult  cases  of  empyema,  I  cannot  recommend  their  em- 
ployment for  children,  unless  perhaps  the  tent  for  a  day  or  two  after  the 
incision;  but  the  tent  is  not  necessary  if  the  catheter  be  daily  intro- 
duced in  the  manner  which  I  have  advised.  The  drainage  tube  almost 
necessarily  admits  air  during  inspiration,  but  this  is  not  the  most  serious 
objection  to  it.  Cachectic  children  with  poorly  nourished  tissues  badly 
tolerate  pressure  upon  an  open  wound  by  a  hard  substance.  It  is  liable 
to  cause  ulceration  and  enlarge  the  opening,  and  continued  pressure  of 
the  tube  ma}'  cause  periostitis  upon  the  edge  of  the  rib  and  necrosis. 
Scrofulous  and  feeble  children  are  very  prone  to  both  caries  and  necrosis 
from  even  slight  pressure  or  bruises  upon  the  surface  of  the  bone — a  re- 
sult to  which  adults  are  much  less  liable.  In  a  paper  publislied  by  Mr. 
AV.  Thomas,^  on  the  treatment  of  empyema  by  resection  of  one  or  more 
ribs,  nine  cases  are  detailed,  in  three  of  which  necrosis  had  occurred 
from  pressure,  it  is  stated,  of  drainage  tubes,  thus  necessitating  the 
removal  of  the  diseased  portion.  During  the  year  1881,  a  wasted 
erapyemic  infant  was  brought  to  one  of  the  institutions  of  this  city  for 
treatment.  After  letting  out  the  pus,  a  drainage  tube  was  introduced 
and  secured.  At  the  next  visit  ulceration  had  so  enlarged  tlie  opening 
that  a  large  amount  of  air  entered  the  chest  with  a  whistling  noise  at 
each  inspiration,  and  was  expelled  during  expiration,  and  necrosis  of  the 
portion  of  the  rib  against  which  the  tube  pressed  had  also  occurred. 
Air  was  finally  excluded  by  covering  the  opening  with  a  cloth  smeared 
on  each  side  with  a  concentrated  solution  of  gutta-percha  in  chloroform, 
but  the  case  after  some  days  ended  fiitally.  The  escape  of  the  drainage 
tube  into  the  pleural  cavity,  which  has  occurred  by  breaking  of  the 
threads  which  secured  it,  is  so  rare  an  accident  that  it  does  not  consti- 
tute an  objection  to  the  introduction  of  the  tube;  but  aspiration  daily  or 
tAvice  daily  through  the  catheter  so  completely  removes  the  pus  that 
drainage  is  not  required,  and  the  risk  of  injury  by  the  pressure  of  the 
tube  is  therefore  avoided. 

oth.  I  have  witnessed,  in  a  few  instances,  the  burrowing  of  pus  under 
the  skin  at  the  point  where  an  incision  had  been  made  to  let  out  the 
pus.  This  complication  may  lead  to  more  or  less  ulceration  or  slough- 
ing, and  it  greatly  increases  the  danger  of  poisoning.  But  infiltration 
of  pus  will  almost  never  occur  if  the  incision  be  direct  through  the 
tissues  and  not  with  the  skin  pushed  to  one  side,  so  that  it  forms  a  cover- 
ing or  valve  when  it  returns,  as  was  once  recommended  in  the  books  as 
a  means  of  excluding  air.  But  air  does  not  enter  the  cavity  through  a 
direct  opening  if  it  be  properly  covered  after  the  pus  has  escaped. 
Burrowing  of  pus  and  pyacmic  poisoning  therefrom  cannot  then  be  re- 

'  Deutsches  Archiv  fiir  Klin,  ^fed.,  Band  IV.,  4  Heft.  London  Jled.  Record, 
Dec.  l;j,  1880. 

'  Birmingham  Med.  Bee,  1880,  N.  S.,  vol.  iii. 


660  XEEYOUS    COUGH. 

gardod  as  an  accident  of  the  mode  of  operation  ^vllicll  I  liavc  recom- 
mended. 

Exsection  of  a  Portion  of  one  or  more  Ribs. — Tins  operation  has 
now  been  performed  a  considerable  number  of  times  in  Europe  and  in 
this  country,  and,  from  the  ])ublished  accounts,  certain  cases  have  ap- 
parently recovered  more  rapidly  in  consequence.  Thus  in  one  case  a 
fistulous  opening,  spontaneously  established,  had  continued  several 
months,  "with  little  diminution  in  the  discharge,  and  very  slow  progress 
toAvard  recovery,  when  by  this  opei-ation,  which  produced  a  larger  open- 
ing and  a  freer  escape  of  pus  and  falling  in  of  the  chest-wall,  so  as  to 
obliterate  the  cavity,  the  patient  rapidly  convalesced. 

The  alleged  benefit  from  the  exsection,  Avhich  consists  in  the  removal 
of  an  inch  or  a  little  more  of  one  or  more  ribs,  in  or  near  the  site  for  the 
usual  performance  of  thoracentesis,  is,  that  there  is  a  readier  escape  of 
pus  and  the  facility  for  washing  out  the  pleural  cavity  is  increased,  and 
the  thoracic  Avail  and  lung  more  readily  approximated  so  as  to  produce 
obliteration  of  the  pleural  cavity.  The  greatest  benefit  is  claimed  for 
it  in  those  cases  in  Avhich  the  intercostal  spaces  are  small  and  the  ribs 
lie  close  to  each  other. 

Without  denying  that  certain  cases  have  apparently  been  benefited 
by  the  operation,  I  must  say  that  I  have  not  yet  met  a  case  either  in 
family  or  hospital  practice,  in  which  I  could  conscientiously  recommend 
the  operation,  except  where  necrosis  had  occurred  from  a  periostitis 
produced  by  the  irritating  property  of  the  pus,  or  the  pressure  of  a 
drainage  tube.  The  gum-elastic  catheter,  introduced  as  recommended 
above,  Avill  pass  through  any  intercostal  space  Avhich  I  have  yet  ob- 
served, so  as  to  alloAV  free  evacuation  of  the  pus  by  suction,  if  it  be  not 
incapsulated  by  fibrinous  bands,  and  alloAv  also  the  free  Avashing  out  of 
the  pleural  cavity  if  this  be  desired. 

There  are  also  serious  objections  to  the  exsection  in  case  of  a  child. 
Tlie  system,  exhausted  by  suppurative  inflammation,  is  in  poor  con- 
dition to  tolerate  an  o])eration  of  any  scA^erity,  and  although  Ave  are 
directed  to  preserve  as  far  as  possible  the  periosteum  from  injury  by  the 
knife,  and  be  careful  not  to  wound  the  intercostal  vessels,  there  are 
necessarily  more  or  less  shock  and  hemorrhage  and  consequent  danger 
of  hastening  the  death  of  the  patient.  In  one  of  the  cases,  that  of  an 
infant,  reported  by  an  advocate  of  the  operation,  it  seems  to  me  that 
death  was  largely  attributable  to  the  exsection. 

In  order  that  exsection  aid  materially  in  the  approximation  of  the 
lung  and  ribs,  it  is  necessary  to  remove  portions  of  tAvo  or  more  ribs, 
and  the  greater  the  operation  the  greater  the  risk.  But  Avhat  is  needed 
is  not  depression  of  the  ribs,  Avhich  may  produce  permanent  deformity, 
but  expansion  of  the  lung,  and  this  is  promoted  by  the  integrity  and 
resiliency  of  the  ribs. 

Nervous  Coug-h. 

A  nervous  cough  sometimes  occurs  in  children,  especially  between  the 
ages  of  two  or  three  and  ten  years.  It  may  result  from  disease  of  the 
brain,  from  the  second  as  well  as  first  dentition,  from  some  irritant  in 


TREATMENT,  661 

the  intestines,  as  worms,  and  also  from  spinal  irritation.  Occasionally 
there  appears  to  be  no  local  cause,  but  a  state  of  auiemia,  or  a  highly 
develoi^ed  nervous  temi>erament,  to  which  it  seems  proper  to  ascribe  the 
couo^h.  Occurring  under  these  last  circumstances  it  corresponds  with, 
and  is  sometimes  accompanied  by,  functional  disturbance  in  the  action 
of  the  heart,  as  palpitation. 

A  nervous  cough  is  short,  painless,  and  without  expectoration.  It 
usually  attracts  little  attention  at  first,  but  from  its  long  duration  the 
friends  finally  become  anxious  lest  it  betoken  some  serious  disease.  At 
times  it  may  nearly  subside  if  the  patient  lead  a  quiet  life  and  the  gen- 
eral health  improve,  and  there  are  periods  of  recrudescence  if  the  oppo- 
site conditions  obtain.  It  may  have  a  spasmodic  character,  especially 
in  times  of  mental  excitement,  but  in  a  less  degree  than  the  cough  of 
pertussis.  If  not  properly  treated,  it  usually  continues  several  weeks 
or  months,  disappearing  as  the  general  health  and  the  tone  of  the 
nervous  system  improve.  It  is  not  in  itself  a  serious  disease,  nor  does 
it  lead  to  any  ailment  or  produce  any  injury  of  the  respiratory  organs, 
but  it  is  an  unpleasant  malady,  and  is  liable  to  be  mistaken  for  incipient 
tuberculosis  if  it  occur  in  one  decidedly  cachectic,  and  belonging  to  a 
family  predisposed  to  phtliisis. 

Treatment. — If  there  be  a  local  cause  of  the  cough,  measures  calcu- 
lated to  remove  this,  or  at  least  to  palliate  its  effects,  are  obviously  re- 
quired. Especially  should  constipation,  or  any  abnormality  in  the 
digestive  function,  be  corrected.  But  in  many  cases  there  is  no  ap- 
parent local  ailment  which  produces  the  cough  by  its  irritative  action, 
and  the  remedial  measures  must  then  be  tAvofold,  to  wit,  measures 
designed  to  improve  the  general  state,  and,  secondly,  measures  designed 
to  relieve  the  cough.  Such  measures  are  also  required  in  most  cases  in 
which  there  is  a  local  cause,  provided  that  the  cough  do  not  cease  when 
treatment  calculated  to  remove  this  cause  has  been  employed. 

For  constitutional  treatment  no  remedy  is  so  useful  in  ordinary  cases 
as  iron.  The  following  example  shows  the  benefit  which  may  result 
from  the  use  of  this  a^ent,  since  in  this  case  it  effected  a  cure  without 
the  aid  of  other  measures.  B — ,  aged  11  years,  pallid  and  of  spare 
habit,  but  active,  and  with  good  appetite,  had  been  treated  for  this 
malady  by  different  physicians  but  without  improvement.  His  mother 
had  died  of  tuberculosis,  and  some  at  least  of  the  physicians  believed 
that  he  was  in  the  commencement  of  the  same  disease.  Finally  he  was 
placeil  under  the  care  of  the  late  Dr.  Cammann,  who,  detecting  the 
nature  of  the  malady,  wrote  the  following  prescription : 

R. — P'erri.  subsulphat.  ......     ^ss. 

Acid,  nitric.  .......     l.^s*. 

Aq.  desliilat. f^^s- — Misce. 

Dose,  three  drops  four  times  daily  in  sweetened  water. 

The  cough  disappeared  in  a  surprisingly  short  time.  If  the  appetite 
be  poor,  the  vegetable  tonics  are  retpiired  in  combination  with  iron. 

If  the  cough  be  fref[ueMt  and  troublesome,  medicines  which  exert  a 
direct  controlling  effect  upon  it  are  required  in  addition  to  the  medicines 
and  measures  employed  to  improve  the  general  state.     For  this  purpose 


662  NERVOUS    COUGH. 

no  remedy  is  so  useful  as  the  bromides,  employed  alone  or  in  combination 
"vvith  belladonna.  If  there  be  no  decided  anjiemia,  and  no  local  cause  of 
the  cough,  the  bromides  and  belladonna  usually  effect  a  cure  without  the 
employment  of  constitutional  measures,  or  if  the  case  seem  to  require 
iron  it  may  be  given  in  the  interval.  The  following  is  the  prescription 
for  a  child  of  three  years : 

R. — Tinct.  belladonnre  ......     gtt.  xxxij. 

Potas.  bromid. 

Ammon.  bniniid.   .......     iia.^j- 

Syr.  simplic. 3ij. — Misce. 

Dose,  one  teaspoonful  twice  daily. 

In  1871  I  was  asked  to  prescribe  for  a  German  boy,  aged  8|-  years, 
who  had  a  cough  of  this  kind  of  two  months'  duration,  Avhich  latterly 
had  been  frequent  and  annoying.  Within  a  week  he  was  entirely  re- 
lieved without  other  remedy,  by  the  employment  of  tincture  of  bella- 
donna, drops  V,  and  bromide  of  ammonium,  gr.  v,  twice  daily.  -  Out- 
door exercise,  or  country  residence,  and  other  regimenal  measures 
which  improve  the  general  health,  are  useful  in  ordinary  cSiSes. 


SECTION  III. 

DISEASES  OF  THE  DIGESTIVE  APPARATUS. 


CHAPTER   I. 

SIMPLE  STOMATITIS,  ULCEROUS  STOMATITIS,  FOLLICULAR 

STOMATITIS. 

Diseases  of  the  digestive  system  are  very  frequent  in  infancy  and 
cliildhood.  They  are  fur  the  most  part  readily  recognized,  and  are 
more  easily  and  quickly  controlled  by  therapeutic  agents,  if  rightly 
applied,  than  are  the  diseases  of  any  other  system.  If  misunderstood 
and  improperly  treated,  they  may,  even  when  mild  and  very  manage- 
able in  their  commencement,  become  chronic  and  obstinate,  or  even 
fatal,  or  they  may  lead  to  other  and  more  dangerous  diseases.  It  is 
necessary,  then,  that  the  physician  should  understand  thoroughly  the 
pathology  as  well  as  therapeutics  of  the  digestive  system,  that  he  may 
make  timely  and  correct  use  of  the  required  remedies. 

The  diseases  of  the  buccal  cavity  in  early  life  are  for  the  most  part 
inflammatory.     The  mildest  is  that  known  as 


Simple  or  Catarrhal  Stomatitis. 

This  form  of  catarrh  occurs  usually  before  the  completion  of  first 
dentition,  and  it  is  most  frequent  under  the  age  of  one  year.  Giving 
rise  in  itself  to  no  severe  symptoms,  and  often  being  connected  with 
other  grave  and  dangerous  maladies,  it  is,  doubtless,  in  many  cases 
overlooked.  It  is  sometimes  confined  to  a  portion  of  tlie  buccal  sur- 
face, or  is  more  intense  in  one  part  than  in  another.  In  other  cases 
the  catarrh  is  uniform,  or  nearly  so,  affecting  the  entire  cavity  of  the 
mouth. 

Causes. — The  common  cause  of  simple  stomatitis  in  infants  is  the 
same  as  that  of  most  cases  of  gastro-intestinal  inflammation  at  that  age. 
This  is  the  use  of  indigestilde  and  therefore  irritating  food,  uncleanli- 
ness,  personal  and  domiciliary ;  in  fine,  all  those  agencies  which  impair 
the  general  health,  and  enfeeble  the  digestive  organs.  Therefore, 
stomatitis,  like  entero-colitis,  is  more  common  in  the  city  than  in  the 
country,  and  among  the  city  poor  than  those  in  the  better  walks  of  life. 
Infants  deprived  of  the  mother's  milk,  and  given  a  diet  which,  with  all 
care  of  preparation,  is  a  poor  substitute  for   the  natural   ailment,  are 

( GG3 ) 


6Qi  SIMPLE    STOMATITIS. 

verv  liable  to  this  disease.  Beaumont  ascertained  from  liis  experiments 
on  St.  ^Martin  that  irritative  changes  produced  in  the  stomach  by  indi- 
gestible substances  were  soon  followed  by  similar  changes  in  the  buccal 
mucous  membrane.  Since  in  young  infants  any  kind  of  artificial  food 
is  less  digestible  than  breast  milk,  it  is  evident  why  those  Avho  are 
prenuiturely  weaned  or  are  carelessly  fed  are  so  liable  to  stomatitis. 
This  inflammation  is  also  sometimes  due  to  irritating  substances  taken 
in  the  mouth,  as  drinks  habitually  too  hot  or  too  cold.  Stomatitis  is 
also  present  in  measles  and  scarlet  fever.  It  then  corresponds  with  the 
cutaneous  eruption,  and  disappears  when  that  subsides. 

Another  cause  is  dentition.  The  gum  over  the  advancing  tooth  first 
becomes  inflamed,  and,  other  causes  perhaps  conspiring,  the  inflamma- 
tion extends  over  more  or  less  of  the  buccal  surface.  When  due  to  denti- 
tion the  stomatitis  is  more  frequently  partial  than  Avhen  it  arises  from  a 
constitutional  cause.  Mercury,  in  whatever  form  introduced  into  the 
system,  excreted  from  the  salivary  gland.^,  and  flowing  over  the  buccal 
surface,  is  an  occasional  though  nowadays  rare  cause. 

Symptoms — Appearances. — Stomatitis,  like  other  mucous  inflam- 
mations, is  characterized  by  increased  redness  and  more  or  less  thicken- 
ing of  the  inflamed  buccal  membrane,  by  rapid  proliferation  and  exfolia- 
tion of  epithelial  cells,  and  by  an  increased  functional  activity  of  the 
muciparous  follicles.  The  heat  of  the  mouth  is  sometimes  augmented 
in  an  appreciable  degree.  The  gums  in  severe  cases  are  swollen  and 
spongy,  and  bleed  easily  if  rubbed  or  pressed.  The  tongue  is  usually 
covered  Avith  a  light  fur,  and  the  salivary  secretion  is  frequently  aug- 
mented to  such  an  extent  as  to  dribble  from  the  corners  of  the  mouth. 
Often  there  is  little  suff"ering,  but  in  other  instances  the  patients  are 
fretful,  experience  jtain  from  the  contact  of  solid  food,  and,  if  nursing, 
may  even  wean  themselves  from  dread  of  pressure  of  the  nipple. 

Simple  stomatitis  is  not  difficult  of  detection,  provided  that  attention 
be  directed  to  the  mouth.  Inspection  informs  us  of  its  presence  and 
extent.  A  fiivorable  termination  may  be  confidently  predicted,  unless 
there  be  a  state  of  marked  cachexia,  or  a  grave  coexisting  disease.  If 
circumstances  are  unfavorable,  simple  stomatitis  may  terminate  in  a 
more  severe  form,  as  the  ulcerous  or  diphtheritic. 

Treatment. — The  physician  should  endeavor  to  ascertain  the  cause, 
and,  if  possible,  should  remove  it  by  appropriate  medicinal  or  hygienic 
measures.  Sometimes  no  special  treatment  is  required,  as  in  measles  or 
scarlet  fever.  AVhen  the  primary  aff"ection  tei'minates,  the  stomatitis 
disappears  of  itself.  If  dentition  be  the  cause,  and  there  be  much  fever 
and  fretfulness,  it  has  been  the  common  practice  to  scarify  the  gums, 
but  this  operation  is  not  often  advisable.  A  few  doses  of  bromide 
of  potassium  relieve  the  fretfulness,  and  mucilaginous  and  mild  astrin- 
gent lotions  suffice  for  the  catarrh.  Borax  is  a  good  local  remedy  used 
either  with  honey  or  with  glycerine  and  water;  one  part  of  borax  to 
three  of  honey,  or  a  drachm  of  borax  to  an  ounce  of  glycerine  and  water. 
A  weak  solution  of  alum  is  also  a  useful  topical  remedy.  'With  either 
of  these  agents  in  a  favorable  condition  of  system,  and  without  any 
serious  coexisting  disease,  the  stomatitis  is  relieved. 


ULCEROUS    STOMATITIS.  665 


Ulcerous  Stomatitis. 

In  ulcerous  stomatitis,  the  anatomical  characters  are  those  of  severe 
simple  stomatitis,  with  the  additional  element  which  gives  it  the  name 
by  which  it  is  designated. 

The  inflammation  usually  begins  upon  the  gums  and  extends  along 
the  buccal  surface.  Little  white  points  soon  appear  upon  the  umler 
surface  of  the  mucous  membrane,  producing  slight  prominence  of  it. 
These  points,  which  are  inflammatory  exudations,  mainly  fibrinous, 
gradually  enlarge.  Some  unite  and  give  rise  to  large  irregular  ulcera- 
tions; others  remain  isolated,  producing  ulcers  which  are  smaller  and 
of  more  regular  shape.  There  is,  indeed,  no  uniformity  as  regards  the 
size  and  form  of  the  ulcers.  In  the  folds  of  the  buccal  membrane  they 
are  usually  elongated,  while  inside  the  lips,  or  where  the  surface  is 
smooth,  the  circular  or  oval  form  predominates.  It  is  a  noteworthy 
fact  that  the  exudation  underlies  the  mucous  membrane,  obstructing  its 
nutrient  vessels,  so  that  the  ulcer  Avhicli  results  causes  destruction  of  the 
mucous  layer,  and  cure  is  eff"ected  by  cicatrization. 

Ulcerous  stomatitis  is  usually  confined  to  that  part  of  the  l)uccal  sur- 
face which  covci's  the  gums,  or  is  in  their  immediate  vicinity,  but  in 
some  instances  it  affects  nearly  every  part  of  the  cavity  of  the  mouth. 

If  the  disease  be  severe,  considerable  SAvellincr  occurs  around  the 
ulcers,  but  the  swollen  part  is  soft  and  cushiony,  and  not  very  tender 
on  pressure.  The  soft  and  yielding  nature  of  the  swelling  serves  as  a 
means  of  diagnosis  betAvcen  this  disease  and  the  premonitorv  stage  of 
gangrene,  since  in  the  latter  affection  the  swollen  part  is  more  indu- 
rated. 

If  the  disease  grow  worse,  more  ulcers  appear,  and  those  already 
present  grow  deeper  and  wider,  and  their  edges  more  vascular. 

If,  on  the  otlier  hand,  there  be  imjjrovement,  the  swelling  subsides, 
the  ulcers  become  more  clean,  their  bases  approach  the  level  of  the 
mucous  membrane,  and  present  a  granulating  appearance.  Finally  the 
mucous  layer  is  reproduced.  A  considerable  time  after  the  ulcers  are 
healed,  the  new  membrane  which  occupies  their  site  has  a  redder  hue 
than  the  adjacent  surface. 

Causes. — Ulcerous,  like  simple  stomatitis,  is  most  frequent  in  the 
families  of  the  poor.  Personal  uncleaidiness,  poor  food,  a  residence  in 
apartments  dirty,  humid,  or  in  other  respects  insalubrious,  favor  its  de- 
velopment. In  fine,  a  cachectic  condition,  however  produced,  is  a  com- 
mon pre<lisposing  cause.  Ulcerous  stomatitis  frequently  occurs  when 
the  system  is  reduced  or  enfeebled  by  acute  diseases,  as  after  the  essential 
fevers  and  thoracic  and  intestinal  inflammations.  In  protracted  entero- 
colitis of  infants,  it  is  sometimes  severe  and  obstinate,  and  a  case  in 
which  this  complication  arises  usually  ends  unfavorably.  The  al)use  of 
mercury  is  an  occasional  cause  of  this  form  of  stomatitis,  as  well  as  of 
simple  catarrh.  Jaccoud  states  that  Bergeron  established  the  fact  that 
ulcerous  stomatitis  is  ])ropagat('d  among  soldiers  by  contagion,  and  he 
adds  ''  it  is  very  probable  that  it  is  the  same  in  infants." 


666  ULCEROUS    STOMATITIS. 

Symptoms. — The  symptoms  in  ulcerous  stomatitis  are  more  severe 
than  in  the  simple  form.  There  are  more  pain,  more  salivation,  and 
more  fretfulness.  The  ulcerated  surface  is  sometimes  very  tender,  so 
that  there  is  hut  little  sleep.  Drinks,  unless  bland  and  lukewarm,  are 
painful,  and,  if  the  ulcers  be  on  the  lips  or  the  front  of  the  mouth,  the 
infant  nurses  less  eagerly  than  usual,  and  even  with  reluctance,  some- 
times weaning  itself.  Occasionally  the  submaxillary  glands  are  tumefied, 
hard,  and  tender.  The  breath  has  an  offensive  odor.  In  mild  cases,  in 
which  the  stomatitis  is  of  limited  extent,  this  odor  may  scarcely  be 
noticed,  but  in  severe  cases  it  is  almost  like  that  exhaled  from  putrid 
substances.     The  febrile  movement  is  usually  slight. 

Prognosis. — A  favorable  prognosis  may  be  given  unless  the  patient 
be  in  a  decidedly  cachectic  condition,  or  there  be  a  serious  coexisting 
disease,  under  which  circumstances  the  case  may  be  protracted.  If 
death  occur,  it  is  due  to  the  cachexia,  or  to  some  pathological  state 
quite  distinct  from  the  stomatitis,  most  frequently  entero-colitis.  Ulcer- 
ous stomatitis,  when  the  ulcers  are  small  and  the  inflammation  of  limited 
extent,  is  of  course  more  easily  cured  than  when  it  is  extensive  and  the 
ulcers  are  large. 

This  disease  is  very  liable  to  return,  unless  the  general  health  be 
good. 

Treatment. — The  physician  should  endeavor  to  ascertain  the  cause 
of  the  stomatitis,  and  so  far  as  possible  should  remove  the  patient  from 
its  influence.  It  is  often  necessary,  in  order  to  insure  speedy  recovery, 
to  recommend  a  change  in  regimen,  especially  as  regards  diet  and  clean- 
liness. If  the  patient  live  in  damp,  dark,  and  dirty  apartments,  the 
family  should  seek  a  better  residence,  and  he  should  be  taken  daily  in 
the  open  air. 

Tonic  remedies  are  generally  required.  The  ferruginous  prepara- 
tions may  be  advantageously  given,  or  the  vegetable  tonics,  or  the  two 
in  combination.  In  selecting  the  internal  remedies  we  must  regard  the 
antecedent  disease,  if  there  be  any,  which  the  buccal  inflammation  com- 
plicates, and  on  which  it  depends.  For  that  large  proportion  of  cases 
in  Avhich  there  is  chronic  intestinal  inflammation,  the  liquor  ferri  nitratis 
Avith  tincture  of  Colombo  administered  in  simple  syrup  Avill  be  found 
useful.  For  local  treatment  Trousseau  recommends  occasional  applica- 
tions of  nitrate  of  silver  or  muriatic  acid  as  a  caustic,  and  in  the  inter- 
vals a  Avash  of  equal  parts  of  borax  and  honey. 

The  chloride  of  lime  is  also  considerably  used  in  Paris.  It  is  recom- 
mended by  Killiet  and  Barthez.  It  is  a})plied  dry  to  the  ulcerated  sur- 
face twice  daily,  and  in  the  interval  the  mouth  is  Avashed  Avith  simple 
Avater.  This  treatment  is  continued  till  the  ulcers  present  a  healthy  ap- 
pearance and  begin  to  cicatrize.  Then  a  Avpak  solution  of  chloride  of 
lime  is  employed,  one  grain  to  forty-five  of  the  vehicle.  By  this  treat- 
ment a  cure  is  usually  effected.  Bouchut  prefers  using  chloride  of  lime 
Avith  honey,  one  drachm  to  the  ounce. 

But  painful  applications  are  not  required.  The  remedy  Avhich  is  most 
employed  in  this  country  and  in  Great  Britain  is  chlorate  of  potassium. 
It  often  acts  like  a  specific  for  this  as  Avell  as  other  forms  of  stomatitis. 
It  may  be  given  dissolved  in  Avater  with  sugar,  or  with  one  of  the  syrups. 


APHTHOUS    STOMATITIS.    .  667 

to  render  it  more  palatable.  The  dose  is  about  two  or  three  grains  every 
two  hours.  It  should  be  alloAved  to  run  over  the  affected  part,  as  it  is 
believed  to  have  u  local  action. 

R. — Potass,  chlorat 3'^--J- 

3Iellis |ss. 

Aquae        .         .         .         .         .         .  .         .         .         •  5  'j  ■ 

One  teaspoonful  every  two  hours. 

Of  all  topical  remedies  in  common  use,  chlorate  of  potassium  is  prob- 
ably the  most  efficacious.  Some  physicians  prefer  the  chlorate  of 
sodium  on  account  of  its  greater  solubility.  If  this  wash  be  too  painful 
in  consec|uence  of  the  irritable  state  of  the  ulcers,  it  may  be  mixed  with 
mucilage  or  be  employed  less  frequently,  and  borax  applied  in  the 
interval. 


Aphthous  Stomatitis. 

Aphthous  stomatitis  may  occur  at  any  age,  but  it  is  most  frequent  in 
childhood.  It  is  sometimes  designated  follicular  stomatitis,  but  the  dis- 
ease affects  the  contiguous  mucous  surface,  as  "well  as  the  seat  of  the 
follicles.  At  first  a  vascular  injection  is  observed,  and  within  a  few 
liouis  a  whitish  exudation  occurs  immediately  under  the  epithelium,  and 
Vpon  the  corium,  in  small  round  or  oval  isolated  spots.  The  smallest 
of  these  patclies  are  not  larger  than  a  pin's  head,  but  most  of  them 
have  a  diameter  of  one  to  two  lines,  and  the^  cause  slight  prominence 
of  the  surface.  In  two  or  three  days  the  exudation  softens,  and  the 
epithelium  which  covers  it  is  tlirown  off,  producing  an  ulcer,  superfi- 
cial, without  induration  of  its  edges,  but  sensitive  to  the  touch.  It  heals 
in  one  to  two  weeks,  leaving  only  a  reddish  spot  or  stain,  which  soon 
fades.  Sometimes  two  or  more  aphthn3  unite,  forming  a  patch,  and  an 
ulcer  of  correspondingly  large  size.  The  seat  of  aphthous  stomatitis  is 
usually  the  internal  surface  of  the  lips  and  cheeks,  the  gums,  tongue,  and 
occasionally  the  roof  of  the  mouth. 

Caused. — Probably  in  most  instances  the  exciting  cause  is  some  de- 
rangement of  the  digestive  organs,  Avhich  may  not  be  appreciable.  We 
sometimes  observe  this  form  of  stomatitis  in  cases  of  diarrhoea.  Occa- 
sionally, especially  in  spring  and  autumn,  two  children  in  a  family  are 
affected  at  tlie  same  time,  or  two  or  more  in  a  school,  so  that  the  disease 
presents  an  epidemic  character.  Children  surrounded  by  bad  hygienic 
conditions,  as  in  the  tenement  houses  of  cities,  are  more  liable  to  this  as 
well  as  other  forms  of  stomatitis,  than  are  children  who  live  in  clean, 
and  airy  localities,  and  have  nutritious  and  ■wholesome  diet. 

Symptoms. — The  constitutional  symptoms  in  a  large  proportion  of 
cases  of  aphtlue  are  slight.  In  twelve  children  affected  with  this  dis- 
ease Billard  found  the  pulse  from  sixty  to  eighty  beats  per  minute. 

The  ulcers  are  )»ainful,  as  is  indicated  by  the  cries  of  the  child  when 
they  are  pressed,  and  its  fretfulness.  Solid  food  and  even  drinks,  unless 
bland  and  unirritating,  are  badly  tolerated.  The  salivary  secretion  is 
also  augmented. 

In   those  rare  cases  in  which  the  ulcers  become  confluent  or  gan- 


668  APHTHOUS    STOMATITIS. 

grenous,  tlic  state  of  tlie  patient  is  really  serious.  There  is  then  often 
gastro-iutestinal  disease.  The  symptoms  indicate  prostration.  The 
pulse  is  feeble,  the  countenance  pallid,  and  the  body  and  limbs  become 
wasted. 

Diagnosis. — This  is  easy.  The  only  disease  ^vitll  -wliich  it  is  liable 
to  be  confounded  is  ulcerous  stomatitis.  In  the  ulcerous  form  there  is 
antecedent  and  accompanying  stomatitis  affecting  a  considerable  ])art, 
if  not  the  entire  buccal  cavity,  Avhile  in  the  follicular  form  the  inllam- 
mation  is  ordinarily  confined  to  the  immediate  vicinity  of  the  ulcers. 
The  character  of  the  ulcers  serves  also  as  a  means  of  distinction.  In 
ulcerous  stomatitis  there  is  great  variety  as  to  size  and  form,  Avhile  in 
aphthous  stomatitis  there  is  great  uniformity  in  both  these  respects.  The 
small,  circular  ulcers  are  characteristic  of  the  follicular  inflammation. 
Before  the  ulcerative  stage  the  circumscribed  character  of  the  eruption 
serves  to  distinguish  this  form  of  stomatitis  from  other  local  diseases 
affecting  the  cavity  of  the  mouth. 

PiiOGNOSlS. — Aphthous  stomatitis  usually  ends  favorably  ;  but,  if 
the  ulcers  become  concrete  or  gangrenous,  the  health  is  seriously  af- 
fected, and  a  more  cautious  prognosis  should  be  expressed.  The  un- 
healthy a])pearance  of  the  mouth  and  the  real  danger  are  more  often 
due  to  the  depressing  effect  of  some  concomitant  disease  than  to  the 
stomatitis. 

Treatment. — In  ordinary  aphthous  stomatitis,  Avhich  is  discrete  and 
attended  by  little  or  no  constitutional  disturbance,  local  remedies  suffice 
to  cure  the  disease.  Demulcent  drinks  or  aj)i)lications  to  the  mouth 
should  be  used,  as  the  mucilage  from  gum  acacia,  nuxrshmallow,  or 
flaxseed.  Mild  astringent  lotions  with  the  demulcent  are  also  bene- 
ficial. The  niel  boracis  is  one  of  the  best  and  most  agreeable  applica- 
tions. It  may  be  placed  in  the  mouth  with  a  spoon,  or  applied  with  a 
camel-hair  pencil.  If  there  be  much  tenderness  of  the  ulcers,  with  rest- 
lessness, a  small  quantity  of  some  opiate  should  be  added  to  the  lotion, 
or  it  may  be  administered  separately. 

With  this  simple  treatment  the  ulcers  generally  soon  heal,  and  the 
health  of  the  patient  is  restored.  If,  however,  the  ulcers  be  painful, 
and  not  disposed  to  heal,  or  be  healing  tardily,  they  may  be  touched 
lightly  with  a  pencil  of  nitrate  of  silver,  or,  as  Barrier  recommends, 
hydrochloric  acid  in  honey  of  roses.  This  diminishes  the  tenderness 
and  expedites  the  healing  process.  A  better  remedy  is  iodoform,  two 
drachms  to  one  ounce  of  ether,  and  applied  to  the  ulcers  by  a  camel- 
hair  pencil. 

If,  as  may  in  rare  cases  occur,  the  ulcerations  be  numerous,  and  ac- 
com])anied  by  considerable  fever,  there  may  be  symptoms  indicative  of 
cerebral  congestion,  or  even  premonitory  of  convulsions.  In  such  cases 
laxatives  and  the  soothinji;  effect  of  one  of  the  bromides  and  sometimes 
of  the  warm  foot-bath  are  required. 

If  there  be  an  unhealthy  appearance  of  the  ulcers,  if  they  gradually 
enlarge  or  become  concrete,  or  gangrenous,  indicating  a  cachectic  state, 
tonics  should  be  employed  with  nutritious  and  easily  digested  diet,  and 
antihygienic  influences  should  so  far  as  possible  be  removed. 


THEU3H.  669 


CHAPTER   II. 

THKUSH. 

The  terms  thrush,  sprue,  and  muguet,  the  last  from  the  French,  aro 
synonymous.  Thej  are  used  to  designate  a  particular  form  of  inflam- 
mation of  mucous  surfaces,  the  peculiar  feature  of  which  is  the  presence 
of  points  or  patches  of  a  curdlike  appearance  on  the  inflamed  surface. 

The  usual  seat  of  thrush  is  the  buccal  membrane,  but  occasionally  it 
affects  the  faucial,  pharyngeal,  or  oesophageal  surface.  It  is  rare  in  the 
subdiaphragmatic  portion  of  the  digestive  tube,  but  a  few  such  cases 
liave  been  reported  by  Billard  and  others.  It  never  affects  the  mem- 
brane of  the  nostrils,  larynx,  or  bronchial  tubes,  and  it  very  seldom 
occurs  in  any  other  part  of  the  alimentary  canal  without  also  being 
present  in  the  mouth.  .  Thrush,  then,  is  a  stomatitis,  pharyngitis,  or 
(jesophagitis,  or  a  gastro-enteritis  with  the  additional  element  which  I 
have  described. 

AxATOMiCAL  Characters. — The  first  stage  of  thrush  is  that  of 
simple  inflammation  of  the  mucous  surface.  There  next  appear  minute 
semi-transparent  points  or  granules,  which,  increasing,  soon  become 
wliite  and  opaque.  Some  of  them  remain  as  points,  while  others,  ex- 
tending, and  perhaps  coalescing  with  those  adjoining,  form  patches  of 
greater  or  less  extent.  The  white  points  or  patches  are  unequally  ele- 
vated. Their  central  part,  which  was  first  formed,  is  most  raised, 
wliile  tlieir  circumference  projects  but  little  above  the  epithelium. 
Tlieir  highest  elevation  is  not  ordinarily  more  than  a  line  al)ove  the  sur- 
face. They  are  smaller  in  the  pliarynx  and  oesophagus  than  upon  the 
Ijuccal  surface.  They  resemble  closely,  in  color  and  consistence,  por- 
tions of  curdled  milk,  and  the  nurse  often  mistakes  them  for  such,  and 
neglects  to  call  attention  to  the  state  of  the  mouth.  They  are  readily 
detached  by  a  little  force,  but  are  speedily  reproduced.  Their  color  in 
the  first  days  of  the  sprue  is  white,  and  sometimes  this  color  continues. 
In  other  cases  they  assume,  if  the  disease  be  protracted,  a  yellow  hue. 

Their  true  nature,  long  unknown,  was  finally  revealed  by  microscopy. 
They  consist  in  part  of  epithelial  cells,  and  in  part  of  a  vegetable 
growth.  This  parasitic  plant  is  in  most  cases  the  oi'dium  albicans.  Like 
other  confervne,  it  consists  of  roots,  branches,  and  sporules.  The  roots 
arc  transparent,  and  they  penetrate  the  ej)it]ielial  layer,  sometimes  even 
to  the  basement  membrane.  The  branches  ilivide  and  subdivide  at  an 
acute  angle,  and  under  the  microscope  they  are  seen  to  consist  of  elon- 
gated cells,  with  one  or  two  nuclei.  Around  these  branches  are 
numerous  sporules.  In  two  or  three  instances  I  have  examined  the 
product  of  thrush  removed  from  the  oesophagus,  and  in  both  the  jiara- 
sitic  plant  Avas  the  penicillium  glaucum,  or  a  conferva  closely  resem- 
bling it. 

In  the  mildest  form  of  thrush,  this  morbid  product  is   in   points  or 


670  THRUSH. 

small  patches.  If  the  patches  be  of  large  extent,  especially  if,  as  rarely 
happens,  a  considerable  part  of  the  buccal  surface  be  covered  by  them, 
there  is  generally  a  state  of  great  prostration  and  danger,  from  some 
antecedent  or  concomitant  disease.  Thrush  is,  indeed,  often  the  sequel 
of  some  grav'C  affection,  as  pneumonitis  or,  gastro-intestinal  inflamma- 
tion. Its  complication  "with  the  last-named  disease  is  common  in  young, 
ill-fed  infants,  esjiecially  those  deprived  of  the  breast-milk,  and  such 
cases  are  frequently  fatal. 

Hence,  some  writers  who  have  observed  infantile  diseases  in  foundling 
hospitals,  regard  thrush  as  one  of  the  most  serious  maladies  of  early  life. 
Valleix,  in  a  book  of  seven  hundred  pages  relating  to  diseases  of  chil- 
dren, devotes  more  than  one-thii'd  to  the  consideration  of  muguet.  Of 
twenty-four  cases,  the  records  of  "vvhicli  he  publishes,  twenty-two  died, 
but  their  death  was  due  to  gastro-intestinal  inflammation,  which  the 
author  considered  a  part  of  the  more  general  disease,  muguet.  Doubt- 
less the  same  cause  which  produced  the  stomatitis,  Avith  the  confervoid 
growth,  in  these  infants,  also  produced  the  fatal  gastritis  or  gastro-ente- 
ritis,  occurring  without  this  growth.  Nevertheless  it  seems  better  to 
restrict  the  term  sprue,  thrush,  or  muguet  to  those  inflammations  of 
mucous  surfaces  which  are  accompanied  by  the  parasitic  gi'owth.  I 
omit,  then,  from  my  description  of  the  anatomical  characters  of  thrush, 
those  sul)diapliragmatic  phlegniasias  which  some  writers  consider  an 
important  part  of  severe  muguet,  and  regard  them  as  complications, 
unless  indeed  the  case  be  one  of  those  exceptional  ones  in  which  the 
parasite  has  lodged  and  grown  upon  the  gastric  or  intestinal  surface. 
This  explanation  seems  necessary  in  order  to  understand  the  difterent 
statements  of  writers  in  relation,  not  only  to  the  anatomical  characters 
of  thrush,  but  also  in  reference  to  its  mortality. 

The  frequent  coexistence  of  thrush  with  gastro-intestinal  inflamma- 
tion, has  been  remarked  in  the  hospitals  of  Europe,  and  in  the  Infant 
Asylum  and  Foundling  Asylum,  in  this  city.  In  the  post-mortem  ex- 
aminations of  those  who  have  died  in  these  institutions,  having  thrush 
at  the  time  of  death  or  immediately  prior  to  it,  and  who  for  the  most 
part  have  been  infants  under  the  age  of  three  months,  I  have  fre(juently 
found  evidences  of  infljtmmation  in  every  division  of  the  alimentary 
canal.  The  confervoid  growtli  was,  however,  seldom  seen  below  the 
fauces,  and  never  beloAV  the  oesophagus. 

Symptoms. — The  symptoms  in  thrush  are  not  different  in  most  pa- 
tients from  those  of  simple  inflammation.  In  the  mildest  cases  they  are 
chiefly  of  a  local  nature,  such  as  have  been  already  described  in  our 
remarks  on  simple  stomatitis.  If  the  inflammation  be  more  extensive, 
especially  if  it  affect  the  fauces  and  oesophagus,  the  infant  becomes 
feverish  and  fretful,  and  the  inflamed  surface  is  .hot,  red,  and  tender. 
In  the  worst  forms  of  thrush  this  surface  not  only  presents  the  ordinary 
features  of  severe  inflammation,  to  wit,  heat,  redness,  and  tenderness, 
but  it  is  sometimes  deficient  in  the  natural  secretion,  so  as  to  present  a 
dry  or  parclied  appt'arance.  It  is  in  these  cases  that  there  is  often  a 
more  extensive  inflammation  than  that  of  the  buccal  or  oesophageal 
membrane.  The  subdiaphragmatic  portion  of  the  digestive  tube  is  in- 
flamed.    In  this  severe  form  of  sprue,  thirst,  loss  of  appetite,  restless- 


PROGNOSIS.  671 

ness,  vomiting,  and  frequently  diarrhoea  occur.  The  countenance  is 
anxious  and  pallid ;  there  is  rapid  emaciation,  and,  if  the  disease  be  not 
arrested,  a  state  of  extreme  prostration  soon  arrives.  The  twenty -four 
severe  cases  related  by  Valleix,  already  alluded  to,  twenty-two  of  which 
were  fatal,  were  examples  of  this  severe  form. 

Causes. — Thrush  most  frequently  occurs  in  those  who  are  constitu- 
tionally feeble,  or  who  are  enfeebled  by  disease  or  by  unfavorable  hygienic 
conditions.  Cachexia  is  a  cause  common  to  thrush  and  most  other  sub- 
acute inflammations  of  the  alimentary  canal.  The  most  obvious  and 
common  of  the  unfavorable  hygienic  conditions  alluded  to  is  the  con- 
tinued use  of  indigestible  and  improper  food.  It  is,  therefore,  a  common 
disease  among  foundlino-s,  in  institutions  where  these  unfortunates  are 
received,  since  they  not  only  breathe  an  atmosphere  which  is  often  im- 
pure, but  are  depriv^ed  of  the  mother's  milk,  and  are  so  frequently  given 
a  diet  which  is  a  poor  substitute  for  it.  Among  the  destitute  of  the 
cities  thrush  is  common,  since  with  them,  from  necessity  or  choice,  there 
is  the  greatest  neglect  of  sanitary  requirements.  Exposure  to  humidity, 
to  variations  in  temperature,  increases  the  liability  to  the  disease,  though 
in  less  dej^ree  than  defective  alimentation.  Billard  and  Valleix  agree 
that  thrush  is  more  frequent  in  the  warm  months  than  in  the  cold,  that 
its  maximum  frequency  is  in  the  months  of  July,  August,  and  Septem- 
ber. Cases  in  the  Infant  Asylum  and  Child's  Hospital  of  this  city, 
have  appeared  to  me  to  correspond  in  this  respect  with  those  related  by 
Billard  and  Valleix.  Various  writers  have  inentioned  the  age  at  which 
thrush  most  frecjuently  occurs  as  one  of  the  predisposing  causes.  Un- 
complicated thrush  is  not  common  above  the  age  of  six  months.  Most 
cases  occur  under  the  age  of  three  months.  Infants  at  the  age  of  one  or 
two  weeks,  if  in  addition  to  lactation  they  are  si)oon-fed  by  nurses  over- 
anxious that  they  should  thrive,  are  liable  to  take  the  disease.  Thrush 
is  not  common  in  children  under  the  age  of  eighteen  months  who  are 
sufferinnr  from  exhaustinrr  diseases.  It  is  then  an  unfavorable  prognostic 
sign. 

Diagnosis. — This  is  easy  so  far  as  thrush  in  the  mouth  is  concerned, 
for  simple  inspection  bv  one  familiar  with  the  disease  is  all  that  is 
required  in  order  to  discover  it.  The  presence  of  thrush  in  portions 
of  the  alimentary  canal  hidden  from  view  cannot  be  positively  ascer- 
tain ed- 

Tlie  vomiting,  diarrhoea,  pain  or  fretfulness,  emaciation,  and  rapid 
sinking,  which  sometimes  accompany  severe  forms  of  thrush,  indicate 
gastro-intestinal  inflammation,  to  which  the  attention  of  the  practitioner 
should  be  chiefly  directed. 

Progxosis. — The  duration  of  thrusli  varies  according  to  its  intensity, 
and  the  favorable  or  unfavorable  condition  of  the  child.  If  it  be  slight 
and  the  healtli  of  the  infant  otherwise  good,  it  may  often  be  cured  in 
two  cr  three  days.  Under  other  circumstances  it  may  continue  as  many 
weeks  or  even  longer,  before  it  is  entirely  removed. 

When  tlirush  occurs  in  connection  with  gastro-cnteritis,  the  mortality 
is  very  great.  It  has  been  already  stated  tiiat  in  Valleix's  twenty-four 
cases  twenty-two  were  fatal.  M.  Anvity  estimates  the  mortality  of  such 
cases  at  nine  in  ten,  and  M.  Godinat  at  two  in  three. 


672  THRUSH. 

Treatment. — As  one  of  the  most  common  causes  of  thrush  is  the 
use  of  indigestible  or  improper  food,  the  physician  should  ascertain  the 
nature  of  the  infant's  diet,  and  if  it  be  faulty,  should  direct  a  better. 
In  many  cases  the  infant  is  bottle-fed.  It  should  be  given  only  the 
mothers  milk  if  practicable,  or  that  of  a  healthy  Avet-nursc.  This 
change  of  alimentation  often  removes  the  sole  cause  of  thrush  in  the 
young  infant,  so  that  it  rapidly  recovers. 

If  artificial  feeding  be  necessary,  such  diet  should  be  advised  as  is 
directed  in  our  remarks  on  the  treatment  of  the  diarrhoeal  maladies. 
There  is  often  in  thrush  an  excess  of  acids  in  the  digestive  tube,  and  an 
alkali  is  required.  Trousseau  recommends  the  addition  of  saccharate  of 
lime  to  the  milk.  Children  Avith  this  disease  should  also  be  taken  from 
filthy  and  damp  apartments,  to  those  in  ■svhich  the  air  is  pure  and  dry, 
and  their  mouths  and  persons  should  be  kept  clean. 

The  remedy  in  common  use  in  the  treatment  of  thrush,  and  which  is 
usually  effectual,  is  borax.  This,  if  applied  sufficiently  often  to  the 
affected  membrane,  not  only  destroys  the  parasitic  growth,  but  prevents 
its  reproduction.  It  is  commonly  employed  with  honey,  or  in  a  powder 
with  suijar  or  dissolved  in  water.  The  officinal  mel  boracis,  consisting 
of  one  part  of  borax  to  eight  of  honey,  is  so  much  used  in  families  that 
it  may  be  considered  almost  a  domestic  remedy.  There  is,  however,  an 
objection  to  using  an  application  for  the  removal  of  thrush  which  con- 
tains either  sugar  or  honey,  since  either  substance  remaining  in  the 
mouth  would  rather  promote  the  growth  of  the  parasite.  Still,  it  is 
desirable  to  employ  a  wash  of  such  consistence  that  it  will  remain  a 
longer  time  in  contact  with  the  buccal  surface  tlian  will  a  simple  solution 
in  Avater.  I  know  no  better  vehicle  for  borax  than  glycerine,  which  has 
the  advantage  of  consistence,  does  not  undergo  any  chemical  change,  and 
has  no  unpleasant  flavor.  Borax  may  be  used  dissolved  in  glycerine, 
with  or  without  some  flavoring  ingredient: 

R. — Sodii  bnrtit ^j. 

CTlyoerina3     .         .         .         .         .         .         .         .      ^ij. 

Aquae    .........      ^vj. — Miscc. 

Borax  sliould  be  used  four  or  five  times  daily,  and  continued  for  a 
time  after  the  disease  has  disappeared  from  sight,  since  the  roots  of  the 
plant  must  be  destroyed  or  the  branches  are  rapidly  reproduced.  It 
should  be  applied  by  a  camel-hair  pencil,  or  with  a  soft  cloth  upon  the 
finger,  or  a  stick.  It  should  be  so  freely  used,  in  extensive  and  severe 
forms  of  the  disease,  tliat  the  infant  will  swallow  some,  since  the  entire 
oesophagus  is  liable  to  be  affected  in  such  cases.  In  the  intervals  between 
the  anplications  of  borax,  if  the  buccal  surfiice  be  hot,  dry,  and  tender, 
so  as  to  increase  the  fretfulness  of  the  infant,  it  is  well  to  use  mucilagi- 
nous washes,  as  the  mucilage  of  acacia  or  marshmallows.  If  the  disease 
continue  notwithstanding  the  use  of  these  mensures,  the  mouth  should 
be  occasionally  washed  with  a  weak  solution  of  nitrate  of  silver  or  sul- 
phate of  zinc: 

R. — Zinci  sulph.  ........     jrr.  ij-iv. 

Aq.  rosae       ........      3ij — Mifce. 


GAXGREXE  OF  THE  MOUTH.  673 

In  many  cases,  however,  the  treatment  of  thrush  is  of  less  importance 
than  that  of  the  disease  which  thrush  compUcates.  The  remedial  meas- 
ures which  I  have  mentioned  then  become  subordinate  to  those  employed 
for  the  graver  disease.  When  this  disease  is  relieved  and  the  general 
health  improves,  thrush  is  more  easily  and  permanently  cured  than 
duriuo-  the  state  of  feebleness  and  ill-health. 


CHAPTEK   III. 

GANGRENE  OP  THE  MOUTH. 

The  diseases  of  the  mouth  which  Ave  have  been  considering  are 
attended  by  little  danger,  but  the  one  which  we  are  next  to  consider 
is  among  the  most  fatal  of  early  life.  It  is  gangrene  of  a  portion  of 
the  cheek  or  gums,  or  of  both.  It  is  described  by  writers  under 
various  names,  as  cancrum  oris,  noma,  necrosis  infantilis,  aqueous 
cancer  of  infants. 

Anatomical  Characters. — Gangrene  of  the  mouth  is  sometimes 
preceded  by  ulceration  of  the  mucous  membrane,  at  the  point  where  it 
is  about  to  commence,  but  in  other  cases  this  membrane  is  entire.  The 
tissues  at  the  point  of  attack,  which  is  most  frequently  the  inside  of  the 
cheek,  become  inflamed,  thickened,  and  indurated.  The  induration 
extends,  and  soon  the  purple  hue  of  gangrene  appears  and  increases. 
The  next  stage  in  tlic  progress  of  gangrene  is  sloughing  of  the  portion 
the  vitality  of  which  is  lost. 

The  slough  does  not  present  the  appearance  of  uniform  decay- 
While  the  color  is  generally  dark,  there  are  in  the  mass  fibres  of  con. 
nective  tissue,  or  even  bloodvessels  which  remain  unchanged  or  are  but 
partially  decomposed.  After  separation  or  sloughing  of  the  part  where 
the  vitality  is  first  lost,  the  surface  of  the  excavation,  if  the  disease  be 
not  checked,  has  a  dark,  jagged,  and  unhealthy  appearance.  Commenc- 
ing with  the  mucous  membrane  and  the  tissue  immediately  underlying 
it,  the  disease  extends  on  the  one  side  toward  the  skin,  and  on  the 
other  toward  the  deeper  seated  structures  of  the  jaw.  According  to 
Billard,  the  swelling  which  precedes  and  surrounds  the  gangrene  is  in 
great  part  oedematous. 

This  disease  is  occasionally  primary,  but  in  a  large  proportion  of 
ea.ses  it  is  secondary.  Occurring  secondarily,  its  symptoms  are  often 
masked  1)y  those  of  the  antecedent  and  coexisting  affection.  Under 
such  circumstances  attention  is  sometimes  first  directed  to  the  mouth, 
by  the  loosening  of  one  or  more  of  the  teeth,  or  the  aj)p('arance  on  the 
skin  of  a  livid  circular  spot,  which  indicates  the  approach  of  the  disease 
to  the  cutaneous  surface.     The  mucous  membrane  presents  a  dark  red 

43 


67-i  GANGREXE    OF    THE    MOUTH. 

appearance  for  the  distance  of  a  few  lines  beyond  the  point  of  ganfrrene. 
It  covers  tissues  wliich  are  intiamed  and  indurated  and  about  to  become 
gangrenous. 

The  tongue  is  usually  more  or  less  swollen,  unless  the  disease  be 
mild ;  an  ottensive  odor  arises  from  the  gangrene,  due  to  the  evolution 
of  sulphuretted  hydrogen  and  other  gases.  There  is  great  difference  in 
the  extent  of  the  destruction,  and  the  gravity  of  the  disease,  in  different 
cases.  It  may  sometimes  be  arrested  by  proper  applications  and  a 
favorable  change  in  the  general  health  of  the  child  at  an  early  period, 
when  there  is  little  loss  of  substance.  In  other  cases  it  extends  till  it 
perforates  the  cheek,  or  even  destroys  a  considerable  part  of  the  side  of 
the  face,  and,  extending  inward,  attacks  the  periosteum  of  the  maxil- 
lary bone,  destroying  the  guni  and  teeth,  and  denuding  the  alveoli. 
Recovery,  if  it  take  place  at  all  under  such  circumstances,  is  with  the 
loss  of  a  portion  of  the  bone,  and  with  deformity. 

The  duct  of  Steno  is  sometimes  included  in  the  gangrenous  portion, 
but  it  commonly  resists  the  destructive  process,  and  remains  pervious. 

Age. — The  age  at  which  gangrene  of  the  mouth  occurs  is  usually 
between  two  and  six  years.  In  twenty-nine  cases  collated  by  Rilliet 
and  Barthez,  tAventy-one  were  between  the  ages  of  two  and  six  years, 
and  the  remaining  eight  between  six  and  twelve  years.  Of  the  cases 
which  have  fallen  under  my  observation,  most  w' ere  between  the  ages  of 
two  and  six  years.  It  is  seen  that  the  period  of  greatest  frequency  of 
gangrene  of  the  mouth  is  different  from  that  in  which  the  ordinary 
forms  of  stomatitis  occur. 

Gangrene  of  the  mouth  may,  however,  occur  under  the  age  of  one 
year.  Billard  reported  three  cases  under  the  age  of  one  month,  but  in 
two  of  these  the  disease  does  not  appear  to  have  been  sufficiently  marked 
to  render  it  certain  that  they  were  genuine  cases. 

CaI'ses. — Gangrene  of  tlie  mouth  usually  occurs  in  those  whose  sys- 
tems are  reduced  or  cachectic.  It  is,  therefore,  more  frequent  among 
the  poor  than  those  in  comfortable  circumstances ;  in  the  city  than  in 
the  country.  It  is  more  frequently  observed  in  asylums  for  children 
than  in  private  practice.  Most  of  the  cases  which  I  have  seen  have 
been  in  these  institutions.  If  the  constitution  be  good,  it  can  only 
occur  in  those  long  deprived  of  pure  air  and  wholesome  nutriment,  or 
those  enfeebled  by  disease. 

Among  the  diseases  which  have  been  known  to  terminate  in  or  be 
followed  by  gangrene  of  the  mouth,  are  the  pulmonary  and  intestinal 
inflammations,  hooping  cough,  and  the  fevers,  both  eruptive  and  the 
non-eruptive.  Rilliet  and  Barthez  have  published  a  table  of  ninety- 
eight  cases  in  which  gangrene  resulted  from  various  diseases.  In  forty- 
nine  of  these  the  antecedent  disease  was  measles,  in  five  scarlet  fever, 
six  hooping  cough,  nine  intermittent  fever,  nine  typhoid  fever,  seven 
mercurial  salivation,  and  five  enteritis.  It  is  seen  that  the  essential 
fevers  were  the  most  frequent  cause  of  the  gangrene.  Of  forty-six 
cases  collected  by  MM.  Boulcy  and  Caillault,  the  antecedent  disease 
was  measles  in  all  but  five.  In  this  city,  also,  a  larger  number  result 
from  measles  than  from  anv  other  disease. 

One  reason  why  so  many  cases  of  gangrene  occur  as  a  sequel  of  measles 


SYMPTOMS, 


675 


is  probably  because  this  disease  is  accompanied  by  stomatitis.  Simple 
or  ulcerous  stomatitis  often  precedes  gangrene. 

Diseases  sometimes  terminate  in  gangrene  of  the  mouth  in  conse- 
quence of  injudicious  treatment,  which  has  lowered  the  vitality  of  the 
system.  Rilliet  and  Barthez  mention  the  case  of  a  child  four  years 
old,  in  whom  gangrene  commenced  at  the  twenty-ninth  day  of  primitive 
pneumonia.  This  child  had  been  reduced  by  the  amplication  of  twelve 
leeches,  three  scarifications,  a  large  blister,  and  by  the  use  of  absolute  diet. 

The  misuse  of  mercury  was  once  a  much  more  frequent  cause  of 
gangrene  than  at  present,  at  least  in  this  country,  since  this  agent  was 
formerly  much  more  employed  than  noAv.  In  fact  most  of  the  affec- 
tions of  infancy  and  childhood  in  which  mercurials  were  formerly  em- 
ployed are  now  treated  without  it. 

Symptoms. — Gangrene  of  the  mouth  so  often  occurs  in  connection 
Avith  other  diseases,  that  its  symptoms  are  in  a  large  proportion  of  cases 
blended  with  those  which  arise  from  a  distinct  pathological  state. 


Fig.  V 


There  is  usually  prostration  more  and  more  pronounced  as  the  gan- 
grene extends.  The  features  are  ordinarily  ])allid,  but  occasionally  tlieir 
normal  color  is  preserved  for  a  time ;  the  expression  of  the  face  is  melan- 
choly, but  composed.  Sometimes  the  child  is  fretful,  if  disturbed ;  at 
other  times  it  will  quietly  consent  to  an  examination.  Tlie  sufTering  is 
not  proportionate  to  the  gravity  of  the  disease.  There  is  less  pain  often 
than  in  some  of  the  f  )rms  of  stomatitis  which  are  unatten<led  with  danger. 

As  the  di.sea.so  advances,  the  body  and  limb.-t  gradually  waste,  the  eyes 
are  hollow,  or,  if  the  gangrene  be  near  tiie  orbit,  the  eyelids  become 
oedematous,.  the  lips  arc  infiltrated,  and  both  the  lips  and  nostrils  are 


676  GANGRENE    OF    TUE    MOUTH. 

often  incrusted.  If  the  cheek  be  perforated,  aliment;ition  is  rendered 
difficult,  and  the  appearance  of  the  chikl  is  melancholy  in  the  extreme. 

The  tongue  is  usually  moist:  it  is  occasionally  swollen.  The  saliva 
flows  from  the  mouth,  either  pure  or  mixed  "with  olTensive  sanguinolent 
matter.  Unless  the  disease  be  slight,  there  is  the  jjeculiar  gangrenous 
odor.  The  appetite  is  sometimes  poor,  at  other  times  it  is  preserved 
through  the  whole  sickness.  There  is  no  vomiting,  or  looseness  of  the 
bowels,  unless  from  a  complication.  The  thirst  is  usually  great,  and 
the  pulse  is  accelerated  and  feeble,  except  in  mild  cases. 

The  skin  in  the  commencement  of  gangrene  is  hot.  When  the  vital 
force  is  much  reduced,  and  especially  as  the  disease  approaches  a  i'atal 
termination,  the  face  and  limbs  become  cool,  and  the  surface  generally 
presents  a  waxen  or  ashy  appearance.  No  derangement  occurs  of  the 
respiratory  system.  Those  cases  which  are  attended  by  a  cough  or 
accelerated  respiration  are  really  cases  of  bronchitis  or  jmeumonia  co- 
existinii;  with  the  muio-rene. 

Diagnosis. — (langrene  of  the  mouth  is  easily  diagnosticated.  In 
those  cases  in  which  ulceration  precedes  the  gangrene,  it  may  be  mis- 
taken in  its  first  stage  for  that  form  of  ulcerous  stomatitis  in  which  the 
ulcers  assume  an  unhealthy  appearance.  The  following  are  the  distin- 
guisliing  features  of  the  two  affections :  Around  the  ulcer  Avhere  gan- 
grene is  about  to  commence  the  tissues  are  greatly  thickened  and  indu- 
rated, or  ocderaatous,  while  ulcerous  stomatitis  begins  with  a  submucous 
deposit  of  fibrin,  and  is  attended  by  little  thickening  of  the  surrounding 
parts,  and  little  or  no  induration  or  oedema.  In  ulcerous  stomatitis  the 
skin  over  the  seat  of  the  disease  presents  its  normal  appearances,  whereas 
in  gangrene  it  presents  a  distended  and  shining  appearance.  The  de- 
structive process  in  ulcerous  stomatitis  is  also  more  limited  than  in  gan- 
gi'ene.  Deep  ulcerations  do  not  occur,  or  are  rare.  Ulcerous  stomatitis 
is  more  readily  healed,  and  it  leaves  no  eschar,  contraction,  or  deformity. 

The  differential  diagnosis  of  gangrene  of  the  mouth  from  those  cases 
of  follicular  stomatitis  in  which  the  ulcers  occupying  the  seat  of  the  fol- 
licles assinne  a  gangrenous  appearance,  must  be  made  by  a  consideration 
of  the  same  facts  or  particulars  which  serve  to  distinguish  it  from  ulcerous 
stomatitis. 

Malignant  pustule,  of  rare  occurrence  in  the  child,  resembles  this  dis- 
ease in  some  of  its  features.  But  the  pustule  ahvays  begins  on  the  skin, 
while  gangrene  is  a  disease  of  the  mucous  surface  primarily.  In  gan- 
grene, therefore,  the  chief  destruction  is  of  the  mucous  membrane  and 
of  the  subnmcous  tissue,  while  in  malignant  pustule  the  chief  destruction 
is  of  the  skin  and  the  subcutaneous  tissue. 

Prognosis. — This  depends  not  only  on  the  extent  of  the  gangrene, 
but  the  nature  of  the  disease,  if  there  be  one,  which  gave  rise  to  it,  and 
the  degree  of  cachexia.  If  it  occur  in  connection  with  or  as  a  sequel 
of  one  of  the  less  debilitating  diseases,  and  there  be  considerable  vigor 
of  system,  it  may  often  be  arrested  when  it  has  destroyed  oidy  the 
mucous  and  subcutaneous  tissues,  so  that  no  deformity  results.  The 
friends  may  congratulate  themselves  if  the  case  terminate  so  favorably. 
In  the  graver  cases,  Avhen  the  gangrene  extends  until  it  destroys  the 
periosteum  of  the  maxillary  bone  on  the  affected  side,  and  perhaps  per- 


TREATMENT.  677 

forates  tlie  cheek,  if  the  child  recover  it  is  ^vith  the  permanent  loss  of 
teeth,  tedious  separation  of  the  necrosed  bone,  and  a  cicatrix  which 
may  interfere  Avith  the  free  use  of  tlie  jaw.  Death  is,  liowever,  tlie 
more  common  termination  of  severe  cases.  Occasionally  the  gangrene 
destroys  the  continuity  of  a  bloodvessel,  causing  abundant  hemorrhage, 
and  accelerating  the  fatal  result.  In  most  cases,  however,  there  is  lirtle 
or  no  hemorrhage,  in  consequence  of  coagulation  in  the  vessels. 

Another  serious  complication  sometimes  arises,  to  wit,  gangrene  of 
other  parts,  as  of  the  external  genital  organs.  The  English  editor  of 
Boucliut"s  treatise  on  diseases  of  children  relates  the  following  interest- 
ing case,  from  the  Transactions  of  the  Edin.  Medieo-Chir.  Society: 

An  infant  eight  months  old  became  affected  with  gangrene  of  the 
face,  head,  and  hands.  "  The  right  ear  and  the  entire  hairy  scalp  were 
of  an  intensely  black  color,  and  on  both  cheeks  patches  existed  about 
the  size  of  a  half-crown  piece.  The  right  thumb  and  the  backs  of  both 
hands  were  similarly  affected.  The  child  was  noted  to  have  been  restless 
and  fev^erish  on  May  22d,  and  on  the  23d  a  slightly  darkened  ring  was 
found  to  have  formed  round  the  thumb,  about  the  middle  of  the  first 
phalanx ;  in  a  few  hours  the  whole  thumb  was  gangrenous,  and  the 
dorsum  of  the  hand  became  involved.  On  the  ear  the  gangrene  com- 
menced with  the  appearance  of  a  fleabite,  and  subsequently  extended 
rapidly  to  the  scalp,  assuming  a  remarkably  regular  form,  and  giving  to 
the  child  the  appearance  of  wearing  a  black  skull-cap.  The  pulse  was 
observed  to  be  very  feeble.  .  .  .  Death  took  place  in  twelve  hours 
from  the  first  appearance  of  gangrene  on  the  thumb,  the  child  being 
sensiljlo  ami  continuing  to  suck  well,  up  to  a  few  minutes  before  death."' 

liilliet  and  Bartliez  state  that  pneumonitis  frequently  occurs  in  the 
course  of  gangrene  of  the  mouth.  Such  a  complication  evidently 
diminishes  materially  the  chance  of  recovery. 

Whether  the  result  be  favorable  or  unfavorable,  it  is  evident,  from  the 
nature  of  the  disease,  that  the  duration  is  very  different  in  different  cases. 
The  physician's  attendance  may  be  re(|uired  for  a  week  or  two  or  for 
several  weeks. 

Treatmext. — As  gangrene  of  the  mouth  is  eminently  a  disease  of 
debility,  all  anti-hygienic  influences  should  be  removed,  and  the  most 
nourishing  diet,  together  with  tonics,  be  recommended.  The  ferrugi- 
nous preparations  or  the  bitter  vegetables  are  required. 

As  soon  as  the  ])hysician  is  called,  he  should  endeavor  to  arrest  the 
gangrene,  accelerate  detachment  of  the  slough,  and  produce  a  healthy 
and  granulating  state  of  the  s-arrounding  tissues.  This  is  best  effected 
by  applying  a  highly  stimulating  or  ev^cn  escharotic  agent  to  the  in- 
flamed surface  underneath  and  around  the  gangrene.  For  this  j)urpose 
a  great  variety  of  substances  have  been  used  by  different  ])hysicians, 
such  as  acetic,  sulphui'ic,  nitric,  and  hydrochloric  acids,  nitrate  of  silver. 
the  acid  nitrate  of  mercury,  chloride  of  antimony,  and  even  th^  actual 
cautery. 

M.  Taupin  recommends,  after  removing  a  considerable  part  of  the 
gangrenous  substances  with  scissors  or  some  instrument,  tlie  application 
of  strong  muriatic  acid,  and,  when  the  slough  is  detached,  of  dry  chloride 
of  lime. 


678  GANGRENE  OF  THE  MOUTH. 

Rilliet  and  Barihez  advised  tlie  use  twice  daily  of  muriatic  acid  or  the 
acid  nitrate  of  mercury,  applied  by  a  brush  upon  and  around  the  slough, 
followed  immediately  by  the  application  of  dry  chloride  of  lime,  when 
the  mouth  is  to  be  thoroughly  washed  with  water  from  a  syringe.  They 
direct  in  the  interval  frequent  ablution  with  water.  After  the  slougli 
has  separated,  the  escharotic  is  to  be  discontinued,  and  the  chloride  of 
lime  used  alone.  If  gangrene  extend  to  the  skin,  a  crucial  incision  is 
to  be  made  and  the  escharotic  applied,  after  which  powdered  cinchona 
is  introduced  and  retained  by  a  plaster.  This  treatment  is  to  be  con- 
tinued till  the  gangrene  is  arrested  and  the  decayed  portion  removed. 
Barrier,  Valleix,  and  most  French  writers,  recommend  essentially  the 
same  treatment,  namely,  the  application  of  undiluted  escharotic  agents. 

A  safer,  less  painful,  and  in  many  cases  successful  treatment,  is  that 
emjdoyed  by  many  British  and  American  physicians,  to  wit,  the  use 
of  escharotic  agents  diluted,  or,  if  applied  in  their  full  strength,  such  as 
are  least  active  and  penetrating.  Some  employ  from  the  first  topical 
treatment  which  is  astringent  and  stimulating  rather  than  escharotic, 
and  they  report  satisfactory  results. 

Dr.  Gerhard  believes  "the  best  local  applications  are  the  nitrate  of 
silver,  if  the  slough  be  small  in  extent ;  if  much  larger,  the  best  es- 
charotic is  the  muriated  tincture  of  iron,  applied  in  the  undiluted  state. 
After  the  progress  of  the  disease  is  arrested,  the  ulcer  will  improve 
rapidly  tinder  an  astringent  stimulant,  such  as  the  tincture  of  myrrh,  or 
the  aromatic  wine  of  the  French  Pharmacopoeia." 

The  local  treatment  recommended  by  Evanson  and  Maunsell  diflFers 
from  that  advised  by  any  of  the  writers  from  whom  I  have  quoted.  A 
knowledge  of  this  treatment,  from  which  I  have  myself  seen  good  results, 
will  be  best  imparted  by  quoting  from  these  authors  :^  "  The  lotion  which 
we  have  found  by  far  the  most  successful  is  a  solution  of  sulphate  of 
copper  as  employed  by  Coates  in  the  Children's  Asylum,  llis  formula 
is  as  follows : 

R. — Cupri  sulph.  .......      Tij. 

Pulv.  ciiichonoe     .         .         .         .         .         .         .      Zi-s. 

Aquas    .........      3i^- — Misce. 

"  This  is  to  be  applied  twice  a  day  very  carefully  to  the  full  extent 
of  the  ulcerations  and  excoriations.  The  addition  of  the  cinchona  is 
only  useful  by  retaining  the  sulphate  of  copper  longer  in  contact  with 
the  edges  of  the  gums.  A  solution  of  the  sulphate  of  zinc.  5j  to  an 
ounce  of  water,  by  itself  or  combined  with  tincture  of  myrrh,  Dr.  Coates 
found  to  be  also  useful  in  some  cases." 

A  moment's  reflection  will  show  us  that  the  above  treatment  is  pre- 
ferable, provided  that  it  is  efjually  effectual  in  arresting  the  gangrene, 
to  the  treatment  by  the  strong  acids  which  are  in  common  use,  and  the 
efficiency  of  which  cannot  be  questioned. 

The  purpose  in  applying  the  acid  is  to  establish  a  healthier  state  of 
the  tissues.  It  cauterizes  and  destroys  whatever  soft  tissue  it  comes  in 
contact  with,  besides  it  produces  a  strong  corrosive  action  on  the  teeth 
and  bone.     Therefore  in  gangrene  affecting  the  jaw,  there  is  great  dan- 

*  Diseases  of  Children,  2d  Amer.  edit.,  page  188. 


TREATMENT.  679 

ger  that  it  will  destroy  the  periosteum,  and  consequently  increase  the 
necrosis. 

Dr.  West/  who  advocates  the  use  of  the  acid,  says:  ''In  one  of  the 
cases  that  I  saw  recover,  the  arrest  of  the  disease  appeared  to  be  en- 
tirely owing  to  this  agent,  though  the  alveolar  processes  of  the  left  side 
of  the  lower  jaw,  from  the  first  molar  tooth  backward,  died  and  exfoli- 
ated, apparently  from  having  been  destroyed  by  the  acid."  No  such 
result  follows  the  use  of  the  solution  of  sulphate  of  copper. 

In  one  of  those  severe  cases  in  which  the  disease  resulted  from  scarlet 
fever,  and  in  which  there  was  so  much  debility  that  an  unfavorable 
prognosis  was  made,  I  succeeded  in  arresting  the  disease  by  the  use  of 
Dr.  Coates's  pi'escription.  The  child  recovered  with  the  loss  of  two 
teeth  and  the  corresponding  portion  of  the  maxillary  bone.  From  the 
good  eifects  which  I  have  observed  from  iodoform,  as  an  ajiplication  for 
ECanfrrenous  vulvitis  followino;  measles,  it  has  occurred  to  me  that  it  may 
also  be  useful  in  gangrene  of  the  mouth. 

If  after  employing  the  milder  treatment  for  two  or  three  days,  the 
gangrene  continue  to  spread,  the  strong  muriatic  acid  should  be  cau- 
tiously applied  by  a  camel-hair  pencil  or  small  swab,  in  such  a  Avay  that 
it  comes  in  contact  only  with  the  diseased  surface.  Its  use  should  be 
immediately  followed  by  an  alkaline  wash,  as  a  solution  of  sodium 
bicarbonate. 

In  1881,  an  epidemic  of  measles  occurred  in  the  New  York  Found- 
ling Asylum  during  the  attendance  of  Drs^O'Dwyer  and  Lee.  The 
number  of  children  affected  with  it  was  165,  and  since  many  of  them 
were  cachectic,  we  were  not  surprised  that  gangrene  appeared  as  a  com- 
plication or  se(|uel  in  seven  cases.  In  a  girl  of  3^  years,  it  appeared 
upon  the  upper  jaw  at  the  base  of  the  teeth;  in  two  girls  of  four  years  it 
aj)peared  uj)on  the  inside  of  the  cheek  and  upon  the  vulva,  and  not  upon 
the  gums;  in  a  boy  of  three  years  it  attacked  the  lower  jaw,  destroying 
f  )ur  teeth  wnth  their  sockets,  and  the  u|)per  jaw,  destroying  five  teeth, 
with  the  corresponding  portion  of  the  maxillary  bone,  so  that  all  the  in- 
cisors and  one  canine  were  lost,  as  well  as  the  cartilaginous  portion  of 
the  nasal  septum.  Gangrene  also  occurred  in  the  groin  in  this  case. 
Another  boy  of  3|  years  lost  two  incisors  from  gangrene  of  the  jaw. 
The  treatment  by  muriatic  acid  was  employed,  and  according  to  the 
house  physician.  Dr.  Kortright,  there  was  no  further  extension  of  the 
gangrene  after  the  first  application  in  any  of  the  cases.  All  lived  ex- 
cept the  first,  wlio  had  broncho-pneumonia.  The  remaining  two  patients, 
ag(Ml  respectively  four  years,  die<l  of  diphtheria  and  ])neumonia  before 
treatment  could  be  tested.  One  of  them  had  commencing  gangrene  of 
the  lower  jaw,  the  other  of  the  soft  palate.  Recently,  in  the  Foundling 
Asylum,  carbolic  acid  has  been  used  as  an  escharotic  in  one  or  two 
cases,  instead  cf  the  strong  acid,  and  with  such  a  result  as  to  encourage 
its  further  use. 

The  gases  arising  from  the  gangrenous  mass  are  not  only  highly  of- 
fensive to  others,  but  they  are  doubtless  injurious  to  the  patient,  who  is 
constantly  inhaling  them.     To  remove  the  fetor,  chlorine  or  carbolic 

'  Diseased  of  Children,  -Jlli  Aincr.  edit. 


680  DENTITION. 

acid,  properly  diluted,  should  be  occasionally  used  between  the  applica- 
tions of  the  sulphate  of  copper.  Labarraque's  solution,  one  part  to 
eight  or  ten  parts  of  Avater,  is  an  eligible  form  for  its  use.  When  the 
gangrene  is  removed,  and  the  granulations  present  a  healthy  appearance, 
all  danger  is  usually  past  anvl  convalescence  is  fully  estaljlished.  Then 
no  enei'getic  topical  treatment  is  required.  A  mild  stimulating  lotion, 
like  the  tincture  of  myrrh,  as  recommended  by  Dr.  Gerhard,  suffices, 
with  the  aid  of  tonics  and  nutritious  diet. 


CHAPTER    lY. 

DENTITION. 

The  opinion  formerly  entertained  in  the  profession,  and  now  preva- 
lent in  the  community,  that  many  infantile  maladies  arise  directly  or 
indirectly  from  dentition,  is  erroneous.  Still  there  are  ])hysicians  of 
experience  who  believe  that  teething  is  a  common  cause  of  certain 
maladies,  especially  of  functional  derangements,  even  of  organs  remote 
from  the  mouth.  On  the  other  hand,  equally  good  observers,  and  the 
number  is  increasing,  almost  wholly  ignore  the  pathological  results  of 
dentition.  They  say  that,  as  it  is  strictly  a  ])hysiological  process,  it 
should,  like  other  such  processes,  be  excluded  from  the  domain  of  pa- 
thology. 

A  moment's  reflection  will  show  hoAV  important  it  is  to  understand 
the  exact  relation  of  dentition  to  infantile  diseases.  Every  physician  is 
called  noAV  and  then  to  cases  of  serious  disease,  inflammatory  and  non- 
inflammatory, which  have  been  allowed  to  run  on  without  treatment,  in 
the  belief  that  the  symptoms  Avere  the  result  of  dentition.  I  have  known 
acute  meningitis,  pneumonitis,  and  entero-colitis,  even  Avith  medical 
attendance,  to  be  overlooked,  and  the  symptoms  attributed  to  teething 
during  the  very  time  when  appropriate  treatment  Avas  most  urgently  de- 
manded. Many  lives  are  lost  from  neglected  entero-colitis,  the  friends 
believing  the  diarrhoea  to  be  symptomatic  of  dentition,  a  relief  to  it,  and 
therefore  not  to  be  treated.  Such  mistakes  are  traceable  to  the  eiToneous 
doctrine,  once  inculcated  in  the  schools,  and  still  held  by  many  of  the 
laity,  that  dentition  is  directly  or  indirectly  a  common  cause  of  infantile 
diseases  and  derangements. 

I  shall  endeavor  to  point  out  Avhat  is  really  ascertained  in  regard  to 
the  pathological  relations  of  dentition. 

The  first  dentition  commences  at  the  age  of  about  six  months  and 
terminates  at  the  age  of  tAvo  and  a  half  years.  The  corresponding  teeth 
of  the  two  sides  pierce  the  gum  at  about  the  same  time.  The  two  infe- 
rior central  incisors  first  appear  at  about  the  age  of  six  or  seven  months, 


PATHOLOGICAL    RESULTS    OF    DEXTITIOX.  (381 

followed,  in  the  order  in  which  they  are  mentioned,  by  the  upper  cen- 
tral incisors,  upper  lateral  incisors,  lower  lateral  incisors,  the  four  ante- 
rior molars,  the  four  canines,  and,  lastly,  the  four  posterior  molars. 

The  incisors  usually  appear  in  rapid  succession,  so  that  all  are  in  sight 
by  the  age  of  one  year.  From  the  age  of  one  year  to  eigliteen  months 
the  anterior  molars  appear,  and  from  the  age  of  sixteen  to  twenty-four 
months,  the  canines,  and  from  twenty-four  to  thirty  months  the  posterior 
mohirs.  Tins  order  is  not  always  preserved.  Sometimes  the  upper 
central  incisors  appear  before  the  lower,  and  sometimes  the  lower  lateral 
before  the  upper  lateral.  In  rare  cases  there  have  been  teeth  at  birth. 
I  have  seen  but  one  or  two  infants  Avith  such  premature  dentition. 
Retarded  dentition  is  much  more  common.  Tho-e  who  have  rickets,  or 
are  feeble  either  constitutionally  or  by  disease,  ofren  have  no  teeth  till 
considerably  after  the  usual  period.  In  such  the  first  incisors  may  not 
appear  till  the  age  of  twelve  months,  or  even  later. 

Pathological  Results  op  Dextitiox. — The  evolution  of  the  teeth 
is  commonly  attended  by  more  or  less  turgescence  around  the  dental 
bulbs.  This  is  greater  with  some  of  the  teeth  than  with  others.  Thus, 
the  superior  incisoi's  cause  more  swelling  than  do  their  congeners  of  the 
inferior  jaw.  The  turgescence,  although  attended  by  more  or  less  con- 
gestion, is  physiological  within  certain  limits,  and  not  a  disease. 

But  sometimes  there  is  an  unusual  amount  of  swelling  around  tlie 
dental  follicles ;  the  afflux  of  blood  to  them  is  greatly  augmented ;  they 
are  the  seat  of  such  a  degree  of  tenderness  k\v\  pain  that  the  infmt  is 
fi-etful.  It  carries  the  finger  often  to  the  mouth,  indicating  the  seat  of 
its  suffering.  The  surfiice  over  the  follicles  presents  greater  redness 
than  in  ordinary  dentition,  and  the  salivai-y  secretion  is  considerably 
increased.     There  is  now  actual  gingivitis. 

Occasionally  the  inflammation  affects  a  greater  extent  of  the  l)uccal 
surface  than  that  lying  directly  over  the  follicles,  so  that  most  Avriters 
speak  of  stomatitis  as  one  of  the  results  of  dentition.  In  a  few  cases  I 
liave  known  such  a  degree  of  inflammation  over  the  advancing  tooth, 
that  a  small  abscess  formed,  producing  much  pain  and  restlessness,  till 
it  was  opened  by  the  lancet. 

The  pathological  results  of  dentition  wliieh  I  have  mentioned,  thoufi^h 
they  may  interfere  more  or  less  with  nursing  or  feeding,  are  not  danger-* 
oils.     They  are  easily  detected.     Tliey  result  directly  from  the  rapid 
growth  and  augmented  sensibility  of  the  dental  follicles. 

There  are  other  supposed  accidents  of  dentition  occurring  in  distant 
parts  of  the  system  in  consequence  of  the  relation  and  interdependence 
of  organs  which  exist  through  the  system  of  nerves. 

Some  children,  previously  to  the  erujition  of  the  teeth,  arc  affected 
with  diarrhfca,  occasionally  accomj)anied  by  irritability  of  stomach. 
Certain  writers  have  supposed  thatgastro-intestinal  catarrh  is  present  in 
these  cases  ;  others  that  there  is  simply  a  hypersecretion,  an  increased 
activity  of  the  intestinal  f  >llicul;ir  ajjjjaratus,  that  it  is,  in  other  words, 
one  of  tlie  forms  of  non-inflammatory  diarrhdca.  Barrier  believes  that 
tlie  diarrhoea  of  dentition  do|)ends  usually  on  what  he  calls  a  "  subinflara- 
matory  turgescence  limitcilto  the  g;\stro-intestinal  fillicular  ap]»aratus," 
I  Ic  believes  that,  in  occasional  cases,  it  is  due  to  defective  or  altered  inner- 


682  DENTITION. 

vation-  It  would  then  be  analogous  or  similar  to  that  form  of  diarrhoea 
which  occurs  in  the  adult  from  the  emotions.  Bouchut  calls  the  diar- 
rhoea of  dentition  nervous  diarrhoea.  It  is  certain,  however,  that  in 
most  cases  of  diarrhoea  which  are  attributable  to  dentition,  there  are 
odier  causes,  such  as  unsuitable  food,  or  residence  in  an  insalubrious 
locality.  It  is  certain,  as  regards  city  infants,  that  the  chief  causes  of 
diarrhoea  during  the  })criod  of  dentition  are  strictly  anti-hygienic,  den- 
tition being  quite  suboi'dinate  as  a  cause,  and  probably  ordinarily  not 
operating  at  all  as  such.  But  when,  as  sometimes  happens,  at  each 
period  of  dental  condition,  the  infant  is  affected  with  diarrhoea,  the 
influence  of  teething  is  a])parent.  Such  cases  enable  us  to  see  that 
teething  may  really  sustain  a  causative  relation  to  certain  diseases  not 
located  in  the  buccal  cavity. 

Among  the  more  common  pathological  results  of  difficult  dentition,  are 
certain  affections  referable  to  the  cerebro-spinal  system.  Eclampsia  is 
one  of  the  admitted  results.  Barrier  attributes  convulsions  in  the  teeth- 
ing infant  to  excitement  of  the  nervous  system  arising  from  the  pain 
which  is  felt  in  the  gums,  and  to  a  determination  of  blood  to  the  dental 
apparatus,  in  which  afflux  the  whole  vascular  system  of  the  hoad  par- 
ticipates. 

In  most  cases  of  convulsions  occurring  during  the  period  of  dental 
evolution,  a  careful  examination  discloses  other  causes  in  addition  to  the 
state  of  the  gums.  Difficult  dentition  must  then  be  considered,  not  so 
frequently  a  direct  as  a  cooperating  or  predisposing  cause,  producing  a 
sensitive  state  of  the  nervous  system,  or  possibly  an  afflux  of  blood  to 
the  head,  of  which  Barrier  speaks,  and  which,  by  an  additional  stimulus, 
perhaps  trivial  in  itself,  ends  in  convulsions.  In  exceptional  instances 
eclampsia  occurs  mainly  from  dentition,  or,  if  there  are  other  causes, 
they  are  quite  subordinate.  This  may  happen  Avhen  several  teeth  pene- 
trate the  gum  at  or  about  the  same  time.  Infants  who  are  burned  or 
scalded  are  very  liable  to  clonic  convulsions.  This  is,  in  fact,  the  chief 
danger  as  regards  life  from  sucli  accidents.  So,  the  swollen  and  tender 
gum,  if  several  teeth  are  about  emerging,  may  affect  the  cerebro-spinal 
system  like  the  burn  or  scald,  and  produce  the  same  nervous  phenomena. 
Thus,  in  a  case  already  alluded  to  in  the  chapter  on  convulsions,  five  in- 
_cisors  pierced  the  gum  within  about  two  weeks,  and  in  this  period  there 
were  two  attacks  of  eclampsia  with  an  interval  of  a  few  days.  The 
attacks  Avere  not  severe,  and  the  most  careful  examination  could  discover 
no  other  cause  than  the  simultaneous  development  of  so  many  dental 
follicles.     Previously,  and  since,  the  inf^xnt  has  been  well. 

Dentition,  sometimes,  though  rarely,  occasions  also  tonic  convulsions. 
The  following  case  occurred  in  the  ])ractice  of  the  late  Dr.  A.  S.  Church, 
of  this  city,  the  history  of  which  he  communicated,  as  follows : 

Case. — "H.,  seven  months  old,  was  first  visited  April  3,  18G3.  The 
patient  had  been  fretful  for  several  days,  but  about  daylight  on  the  morn- 
ing of  my  first  visit  it  commenced  crying,  and  had  not  ceased  for  a  moment 
at  the  time  of  my  visit,  9  a.  m.  The  bowels  were  somewhat  constipated 
and  tympanitic;  abdominal  muscles  very  tense.  The  pain  was  supposed 
to  be  in  the  abdomen,  and  a  brisk  cathartic,  to  be  followed  by  an  ano- 
dyne, was  ordered.     Some  relief  followed,  but,  on  the  ensuing  and  for 


.DIAGNOSIS.  683 

several  consecutive  mornings,  the  pain  returned,  each  day  lasting  longer, 
until  the  child  only  ceased  crying  -while  under  the  influence  of  a  full  ano- 
dvne.  The  gum  over  the  npper  incisors  was  considerably  swollen,  hot, 
and  dry,  but  the  parents  would  not  consent  to  have  it  scarified.  P^or  the 
first  week  there  was  no  fever,  no  vomiting,  and  not  the  least  indication 
that  the  nervous  system  Avas  suflering.  About  the  10th  the  thumbs  were 
noticed  to  be  flexed  during  the  attack  of  paia,  and  about  the  15th  the 
flexors  of  the  toes  were  contracted  and  the  hands  were  turned  backward 
and  outward,  but  only  while  the  child  was  awake.  About  the  20th  there 
was  constant  contraction  of  the  flexors  of  both  extremities,  with  opisthot- 
on  )s,and  constant  rolling  of  the  head,  loss  of  appetite,  progressive  emacia- 
tion, coated  tongue,  and  highly  inflamed  gums.  Consent  was,  finally,  ob- 
tained to  relieve  the  inflamed  gum,  and  free  incisions  were  made,  and  the 
following  night  the  child  slept  comfortably  for  three  hours  with«jut  opi- 
ates. In  three  days  the  gums  were  freely  cut  again,  and  the  teeth  soon 
made  their  appearance.  All  symptoms  of  disease  had  now  ceased,  the 
child  became  playful,  and  on  o()th  the  pa' lent  was  discharged." 

The  opinion  has  been  prevalent  in  the  profession,  that  painful  and 
difficult  dencition  is  one  of  the  chief  causes  of  infantile  paralysis,  but  it 
is  now  commonly  admitted  that  it  is  only  a  subordinate  or  remote  cause, 
if  indeed  it  is  proper  to  consider  it  as  a  cause  at  all.     (See  Art.  Paralysis.) 

Some  writers  express  the  opinion  that  acute  meningitis  occasionally 
results  from  teething.  The  fticts,  however,  that  are  relied  upon  to  prove 
this  are  uncertain.  The  occurrence  of  meningitis  during  dentition  is 
probably  in  most  instances  a  coincidence. 

Teething  less  frequently  disturbs  the  respiratory  system  than  either 
the  digestive  or  cerebro-spinal.  A  cough  occurs  in  some  infants  at  each 
period  of  dental  evolution.  It  is  attended  by  little  expectoration,  but 
appears  to  be  associated  with,  in  at  least  certain  cases,  an  inflammatory 
turgcscence  of  the  bronchial  mucous  membrane. 

Acceleration  of  pulse  is  often  observed  at  the  time  of  greatest  swell- 
ing and  tenderness  of  the  gum.  It  subsides  ■with  the  protrusion  of  the 
tooth.  The  febrile  movement  of  dentition  is  irregular,  sometimes  pre- 
senting a  remittent  form,  like  remittent  fever  or  the  fever  premonitory 
of  meningitis.  Eczema  and  certain  other  cutaneous  diseases  are  common 
during  dentition,  but  their  dependence  on  it  as  a  cause  has  not  been 
demonstrated. 

Dfagnosis. — Tlie  accidents  of  dentition  which  are  located  in  the 
nioutii  are  easily  diagnosticated,  except  the  odontalgia  which  Avriters 
describe,  and  which  is  not  necessarily  attended  by  any  i)crceptible  ana- 
tomical alteration  of  the  gums.  Those  accidents  which  pertain  to  re- 
mote anil  concealed  organs  are  usually  detected  "with  ease,  though  it  is 
often  difficult  to  determine  "with  certainty  their  relation  to  dentition. 

When  similar  symptoms  arise  at  each  epoch  of  teething,  and  subside 
with  the  subsidence  of  tiio  gingival  turgcscence,  teething  must  be  re- 
garded as  the  cause.  Or,  if  the  disease  be  such  as  is  known  to  he 
produced  occasionally  by  difficult  teething,  and  if,  after  a  careful  ex- 
amination, we  can  discover  no  other  cause,  while  the  gums  are  swollen, 
especially  over  two  or  more  advancing  teeth,  it  is  proper  to  refer  the 
malailv  to  dentition. 


08-i  DENTITION, 

It  is  evident  that  we  must  often  be  in  doubt  whether  the  dise<ase 
we  are  treating  be  due  at  all  to  the  state  of  the  gums,  or,  if  so,  whether 
directl}''  or  indirectly,  or  to  what  extent ;  but,  as  a  rule,  if  any  other 
cause  be  apparent,  we  may  properly  regard  the  influence  of  dentition  as 
quite  subordinate. 

Treatment. — It  is  obvi.ous  that  remedial  measures  in  cases  of  difficult 
dentition  must  be  twofold,  namely,  those  directed  to  the  state  of  the 
gums,  and  those  designed  to  relieve  the  derangements  or  diseases  to 
Avhich  dentition  has  given  rise.  If  there  be  diarrha3a,  this  should  be 
controlled  by  proper  remedies,  so  as  to  reduce  the  niuuber  of  evacua- 
tions to  two  or  three  daily.  It  is  well  to  state  to  the  friends  of  the 
ciiild,  who  believe  that  diarrhoea  is  salutary  during  the  period  of  teeth- 
ing, that  this  number  is  quite  sufficient,  and  that  more  frequent  evacua- 
tions endanger  the  safety  of  the  child. 

The  nervous  affections,  as  convulsions,  require  such  soothing  and  de- 
rivative measures  as  are  recommended  in  our  remarks  on  diseases  of  the 
nervous  system.  The  bromide  of  potassium  I  have  found  especially 
useful  and  safe  in  cases  of  fretfulness  and  nervous  excitement  due  to 
dentition.  Demulcent  and  soothing  lotions  are  sometimes  useful  in 
cases  of  painful  dentition,  and  the  infant  may  be  allowed  to  hold  in  its 
mouth  an  India-rubber  or  ivory  ring,  Avhich  seems  to  give  considerable 
relief. 

Mothers  often  attempt  to  "rub  through  a  tooth,"  as  they  term  it,  by 
means  of  a  ring  or  thimble.  This  should  be  discouraged.  So  great 
friction  cannot  fail  to  have  an  injurious  effect,  by  increasing  the  SAvelling 
and  inflammation,  unless  the  tooth  have  already  reached  the  mucous 
membrane. 

We  come  now  to  a  subject  which  has  engnged  the  attention  of  many 
physicians  of  ample  experience,  and  in  reference  to  which  there  is  still 
a  difference  of  opinion  among  the  highest  authorities  in  medicine.  I 
refer  to  scarification  of  the  gums. 

The  gum-lancet  is  much  less  frequently  employed  than  formerly. 
It  is  used  more  by  the  ignorant  practitioner,  who  is  deficient  in  the 
ability  to  diagnosticate  obscure  diseases,  than  by  one  of  intelligence, 
who  can  discern  more  clearly  the  true  pathological  state.  Its  use  is 
more  frequent  in  some  countries,  as  England,  under  the  teaching  of 
great  names,  than  in  others,  as  France,  where  the  highest  authorities, 
as  Killiet  and  Barthez,  discountenance  it. 

It  is  well  to  bear  in  mind,  as  aiding  in  the  elucidation  of  this  sulyect, 
the  remark  made  by  Trousseau,  that  the  tooth  is  not  released  by  lancing 
the  gum  over  the  advancing  crown.  The  gum  is  not  rendered  tense  by 
pressure  of  the  tooth,  as  many  seem  to  think,  for,  if  so,  the  incision 
would  not  remain  linear,  and  the  edges  of  the  wound  would  not  unite, 
as  they  ordinarily  do,  by  first  intention  within  a  day  or  two.  This 
speedy  healing  of  the  incision,  unless  the  tooth  be  on  the  point  of 
protruding,  is-  an  important  fact,  for  it  shows  that  the  effect  of  the  scari- 
fication can  last  only  one  or  two  days.  The  early  repair  of  the  dental 
follicle  is  probably  conservative,  so  far  as  the  development  of  the  tooth 
is  concerned.  It  may  help  us  to  understand  how  active,  how  ])Owerful, 
the  process  of  absorption  is,  if  we  reflect  that  the  roots  of  the  deciduous 


SECOXD    DEXTITIOX.  685 

teeth  are  more  or  less  absorbed  by  tlie  advancing  second  set,  -without 
much  pain  or  suffering  from  the  pressure.  If  the  calcareous  particles 
of  the  teeth  are  so  readily  absorbed,  what  is  the  foundation  for  the 
belief  that  the  fleshy  substance  of  the  gum  is  absorbed  'with  such  difS- 
culty  ?  Too  much  importance  has  evidently  been  attached  to  the  sup- 
posed tension  and  resistance  of  the  gum  in  the  process  of  dentition. 

Follicles  in  the  period  of  development  are  especially  liable  to  inflam- 
mation. We  see  this  in  the  follicular  stomatitis  and  enteritis  so  com- 
mon when  the  buccal  and  intestinal  follicles  are  in  a  state  of  most  rapid 
growth.  Does  not  this  law  in  refc'i-ence  to  the  follicles  hold  true  of 
those  by  which  the  teeth  are  formeil,  so  that  the  period  of  their  enlarge- 
ment and  greatest  activity,  which  corresponds  with  the  growth  and  pro- 
trusion of  the  teeth,  is  also  the  period  when  they  are  most  liable  to  con- 
gestion and  inflammation  ?  It  seems  probable  that  the  dental  follicles 
are  most  liable  to  become  inflamed,  and  therefore  tender,  from  various 
causes  apart  from  dentition,  at  the  time  of  their  greatest  functional 
activity. 

If  tliere  be  no  symptoms  except  such  as  occur  directly  from  the 
swelling  and  congestion  of  the  gum,  the  lancet  should  seldom  be  used. 
The  pathological  state  of  the  gum  which  would,  without  doubt,  require 
its  use,  is  an  abscess  over  the  tooth.  As  to  the  symptoms,  Avhich  are 
general  or  referable  to  other  organs,  as  fever  and  diarrhoea,  the  lancet 
should  not  be  used  if  the  symptoms  can  be  controlled  by  other  safe 
measures.  All  cooperating  causes  should  first  be  removed,  when  in  a 
large  proportion  of  cases  the  patient  will  experience  such  relief  that 
scarification  can  be  deferred. 

If  the  state  of  the  infant  bo  one  of  immediate  danger,  as  in  eclampsia, 
and  it  be  not  quickly  relieved  by  the  ordinary  remedies,  scarification 
may  not  only  be  proper  but  required  to  insure  safety.  For  in  such  cases 
all  measures,  provided  that  they  are  safe  and  simple,  which  can  possibly 
give  relief,  should  be  employed  without  delay.  But  I  can  recall  to  mind 
only  two  accidents  of  dentition  which  would  be  likely  to  be  benefited  by 
scarification,  namely,  suppurative  inflammation  in  the  dental  follicle  and 
convulsions.  But  since  the  bromide  of  potassium  and  hydrate  of  chloral 
have  come  into  use  as  nervous  sedatives,  and  as  efficient  remedies  for 
clonic  convulsions,  scarification  of  the  gums  is  much  less  frequently  re- 
quired, for  even  severe  eclampsia  commonly  yields  to  these  medicines, 
if  the  condition  of  the  bowels  be  attended  to. 


Second  Dentition. 

The  fact  is  well  established,  though  often  overlooked  in  practice,  that 
second  dentition  occasionally  deranges  the  functions  of  organs,  and  gives 
rise  to  pathological  symptoms.  Ivillict  and  Barthez  mention  ])articu- 
larly  neuralgic  pains,  rebellious  cough,  and  diarrh(ca,  as  effects  which 
they  have  observeil.  liilliet  relates  the  case  of  a  girl,  eleven  years  old, 
who  had  a  very  obstinate  and  j)rotracted  cough,  tlie  paroxysms  lasting 
often  half  an  hour  to  one  hour.  This  cough  immediately  and  perma- 
nently disappeared  when  the  molars  pierced  the  gums. 


686  SECOND    DENTITION. 

Dr.  James  Jackson^  says:  "  I  have  seen  persons  between  twenty  and 
thirty  years  of  age  much  affected  by  a  wisdom  tooth  not  yet  protruded, 
and  distinctly  relieved  by  cutting  the  gum.  ]>ut  I  thiidc  the  most  com- 
mon period  of  suffering  from  the  second  dentition  is  from  the  tenth  to 
the  thirteenth  year.  The  most  characteristic  affections  are  wasting  of 
flesh  and  nervous  diseases.  The  boy  loses  his  comeliness,  and  his  com- 
})lexion  is  less  clear,  while  emaciation  takes  place  in  every  part,  thouo-h 
mostly,  perhaps,  in  the  face.  The  nervous  symptoms  are  various,  but 
the  most  common  are  a  change  in  the  temper  and  a  loss  of  spirits.  With 
these  there  is  some  loss  of  strength.  The  patient  is  unwilling  to  engage 
in  play,  and  soon  becomes  tired  when  he  does  do  it.  Among  the  dis- 
tinct symptoms  which  are  not  uncommon,  I  may  mention  pain  in  the 
head  and  in  the  eyes.  The  headache  is  not  commonly  severe,  but  it  is 
such  as  inclines  the  patient  to  keep  still.  The  eyes  are  not  only  pain- 
ful, but  are  often  affected  Avitli  the  morbid  sensibility  to  which  these 
organs  are  subject.  I  have  known  boys  truly  anxious  to  pursue  their 
studies  obliged  to  give  them  up  on  this  account;  and  these,  not  having 
the  disposition  to  play,  will  of  choice  pass  the  day  with  their  mothers, 
and  increase  their  troubles  for  the  want  of  air  and  exercise.  Nervous 
affections  of  a  more  severe  character  are  sometimes  manifested." 

Whether  the  symptoms  Avhich  have  been  attributed  to  second  denti- 
tion have  always  been  due  to  this  cause,  is  questionable.  Practically, 
however,  it  matters  little  whether  Ave  recognize  dentition  as  the  cause, 
or  assign  something  else.  Hygienic  and  medicinal  measures  to  improve 
the  general  health  will  usually  suffice  to  relieve  the  patient.  Elsewhere 
I  have  related  the  case  of  a  boy,  of  nervous  temperament,  a1)out  seven 
years  old,  who  recovered  immediately  from  a  cough  Avhicli  had  lasted 
for  several  weeks,  by  taking  a  mixture  of  iron  and  nitric  acid.  Many 
do  well  Avithout  medicine,  simply  by  hygienic  measures.  Dr.  Jackson 
says:  "The  remedies  Avhich  I  have  found  most  usefrrl  areas  folloAvs: 
First,  a  relief  from  study  or  from  regular  tasks,  yet  using  books  so  far 
as  they  aff'ord  agreeal)le  occupation  or  amusement.  Second,  exercise  in 
the  open  air,  preferring  the  mode  most  agreeable  to  the  patient,  and  in 
more  grave  cases  the  removal  from  toAvn  to  country." 

^  Letters  to  a  Young  Phy&iciati. 


CATARRHAL    PHARYXGITIS.  687 


CHAPTER    Y. 

CATAKRHAL  PHARrXGTTIS,  PERI-PHARYXGEAL  ABSCESS. 
OESOPHAGITIS. 

Children  of  all  ages  are  liable  to  inflammation  of  the  pharynx.  In 
its  mildest  form  it  often,  doubtless,  escapes  detection  in  the  young  in- 
fant. In  older  patients  it  is  revealed  by  pain  in  swallowing  solid  food, 
and  more  or  less  tumefaction  below  the  ears,  apparent  to  the  sight.  It 
is  saiil  to  be  less  frequent  in  infancy  than  in  childhood.  In  the  adult, 
and  in  children  over  the  age  of  four  or  five  years,  inflammation  of  the 
pharyngeal  surface  is  often  confined  to  the  portion  of  membrane  which 
covers  or  immediately  surrounds  the  tonsils.  It  occurs  in  connection 
with  inflammation  of  these  glands.  But  in  infancy  and  early  childhood 
this  limitation  is  comparatively  rare.  Catarrhal  inflammation  of  the 
fauces  at  this  age  is  ordinarily  general,  the  tonsils  particijiating  in  the 
morbid  state. 

Pharyngitis  is  primary  or  secondary.  The  secondary  form  occurs  in 
measles,  scarlet  fever,  bronchitis,  croup,  pneumonitis,  and  occasionally 
in  other  affections.  As  these  diseases  are  common,  pliysicians  are 
oftener  called  to  treat  patients  who  have  the  secondary  form  than  the 
primary.  Ivilliet  and  Barthez  met  eighty-three  secondary  to  sixteen 
primary  cases. 

Anatomical  Characters. — The  pathological  anatomy  of  pharyn- 
gitis is  ascertained  by  depressing  the  tongue  and  inspecting  the  fauces. 
The  faucial  surface  is  seen  to  be  redder  than  in  health,  with  more  or 
less  swelling,  according  to  the  intensity  of  the  inflammation.  In  the 
primary  inflammation  the  color  is  commonly  bright  red,  almost  like  that 
of  arterial  blood.  If,  on  the  other  hand,  the  inflammation  occur  in 
connection  with  a  constitutional  malady,  the  hue  is  often  darker.  In 
grave  cases  of  scarlet  fever  or  measles  it  is  sometimes  even  livid,  indi- 
cating a  vitiated  state  of  the  blood,  a  condition  of  real  danger.  The 
tonsils  are  tumefied  so  as  to  project,  though  not  to  the  extent  Avhich  we 
observe  in  the  adult.  They  are  then  less  firm  than  in  the  normal 
state.  The  follicles  of  the  throat  are  enlarged  and  active,  pouring  out 
a  muco-purulent  secretion.  This  is  sometimes  seen  in  a  layer  over  the 
tonsil  or  the  posterior  y)ortion  of  the  fauces.  In  a  case  of  primary 
pharyngitis  examined  after  death  by  Rilliet  and  Barthez,  the  tonsils 
were  softened,  infiltrated  with  pus,  and  slightly  enlarged.  A  layer  of 
bloodv  mucus  lav  on  the  pharyngeal  surface,  which  was  dark  red,  thick- 
ened,  and  glandular.  The  submaxillary  glands  were  also  swollen  and 
someAvhat  softened. 

If  the  iidlammation  be  intense,  the  deep-seated  portions  of  the  tonsils 
become  involved,  and  even  sometimes  the  adjacent  connective  tissue. 
In  such  cases,  by  applying  the  fingers  in  the  hollows  belnw  the  cars, 
the  tonsils  can  be  felt. 


688  CATARRHAL    P  II  A  R  Y  ><:  GITIS. 

Causes. — The  usual  cause  of  primaiy  pharyngitis  is  exposure  to 
cold.  It  also  occasionally  occurs  from  the  use  of  drinks  too  hot  or  con- 
taining some  irritating  substance.  I  have  met  it  in  the  most  intense 
form  caused  by  s'wallowing  boiling  water,  and,  in  one  case,  from  acetic 
acid  taken  through  mistake.  When  it  occurs  in  the  eruptive  fevers,  it 
is  usually  part  of  a  more  extensive  phlegmasia,  in  which  the  buccal  and 
perhaps  laryngeal  and  nasal  surfaces  participate. 

Symptoms. — Fever,  with  thirst  and  loss  of  appetite,  is  common,  and 
is  usually  proportionate,  in  intensity,  to  the  extent  and  severity  of  the 
inflammation.  At  first  there  is  dryness  of  the  faucial  surface,  and  this  ■ 
is  succeeded  by  a  more  or  less  abun<lant  viscid  secretion.  Swallowing 
is  painful,  except  in  mild  cases.  The  muscles  of  the  anterior  half 
arches,  Avliich  by  their  contraction  close  the  opening  from  the  pharyn- 
geal to  the  buccal  cavity,  and  those  of  the  posterior  arches,  which  close 
the  opening  to  the  nasal  cavity,  both  which  sets  lie  a  little  under  the 
mucous  membrane,  are  often  so  infiltrated  with  serum  that  their  con- 
tractile power  is  diminished,  and  if  the  same  happen  with  the  constrictor 
muscles,  which  carry  downward  tlie  food,  swallowing  becomes  difficult, 
and  in  the  attempt  more  or  less  of  the  ingesta  is  liable  to  return  into  the 
mouth,  or  enter  the  nostril.  During  health  the  air  passes  through  the 
nostrils  in  the  pronunciation  of  two  letters  only,  namely,  N  and  M,  but 
in  severe  pharyngitis,  in  conserjuence  of  tlie  swelling,  and  the  impair- 
ment of  the  action  of  the  muscles  concerned  in  speech,  the  air  passes 
through  the  nostrils  with  the  utterance  of  many  Avords,  producing  the 
nasal  tone  of  voice.  Sometimes  the  inflammation  traverses  the  Eus- 
tachian tube  to  the  middle  ear,  causing  earache,  which  may  be  relieved 
by  the  escape  of  pus  down  the  tube,  or  by  perforation  of  the  drum  into 
the  external  car. 

The  breath  is  foul,  but  not  fetid ;  the  respiration  normal,  or  but 
slightly  accelerated  ;  there  is  commonly  no  cough,  but  it  is  sometimes 
present,  due  to  the  extension  of  the  inflammation  to  the  upper  part  of 
the  larynx,  or  to  the  collection  of  mucus  around  the  aperture  of  the 
glottis.  In  most  cases  of  pharyngitis  a  light  fur  covers  the  tongue,  and 
stomatitis  of  a  mild  grade  is  present,  as  shown  by  redness  of  the  buccal 
surface,  and  increased  mucous  secretion. 

Chronic  pharyngitis,  which  is  so  common  in  adults,  and  which  is  pro- 
duced in  some  by  gastric  derangements,  and  in  others  by  excessive 
smoking,  or  the  prolonged  use  of  intoxicating  drinks,  and  in  others,  still, 
by  the  syphilitic  or  mercurial  cachexia,  is  comparatively  rare  in  children. 

PpiOGXOSIS. — In  mild  cases  of  pharyngitis  convalescence  commences 
Avithin  a  Avcek.  If  the  inflammation  be  dei)endeiit  on  a  constitutional 
malady  it  may  continue  consideral>ly  longer,  especially  if  the  glands  of 
the  neck,  and  the  connective  tissue,  be  much  involved.  Tlie  prognosis 
in  secondary  pharyngitis  is  less  favorable  than  in  that  of  the  primary 
form.  In  fatal  cases  there  is  usually  a  vitiated  state  of  the  blood,  cither 
from  the  coexisting  constitutional  disease,  or  from  previous  cachexia. 

Pharyngitis  may,  however,  become  dangerous  from  complications  to 
Avhich  it  gives  rise.  The  proximity  of  the  inflammation  to  tlie  brain,  or 
its  effect  upon  the  cerebro-spinal  axis  through  the  medium  of  the  nerves, 
sometimes  gives  rise  to  clonic  convulsions.     In  a  recent  case  of  primary 


TREATMENT.  639 

pharyngitis  in  my  practice,  repeated  and  violent  convulsions  occurred  in 
an  infant,  about  one  year  old,  from  this  cause.  They  commenced  at  the 
inception  of  the  inflammation,  and  constituted  the  only  real  danger. 
Pliarvngitis  may  interfere  materially  with  nutrition  in  consequence  of 
the  dyspiiagia,  but  in  most  cases  of  primary  pharyngitis  this  symptom 
does  not  continue  sufficiently  long  to  endanger  the  life  of  the  patient. 
In  grave  constitutional  affections,  as  scarlet  fever,  the  difficulty  of  swal- 
lowing, and  the  consequent  innutrition,  augment  the  danger.  As  re- 
gards, therefore,  the  prognosis  in  catarrhal  pharyngitis,  whether  primary 
or  secondary,  it  may  be  stated  as  a  rule,  that  it  is  not,  per  se,  a  fatal 
disease,  but  is  only  so  from  complications,  or  from  aggravating  the 
primary  malady  with  which  it  is  associated. 

Diagnosis. — Tliis  is  not  difficult  provided  that  attention  be  directed 
to  the  throat;  but  the  physician  often  fails  to  discover  it  at  his  first 
visit,  from  neglecting  to  examine  this  part.  In  many  cases  the  local 
symptoms  are  not  well  marked,  and  in  the  absence  of  these  the  febrile 
reaction  may  at  first  be  referred  to  some  other  cause  than  the  true  one. 
Inspection  not  only  reveals  the  presence  of  inflammation,  but  enables  us 
to  determine  whether  it  be  simple  pharyngitis,  or  diphtheritic  or  ulcera- 
tive. In  some  instances,  simple  pharyngitis  resembles  the  diphtheritic, 
from  the  presence  of  confervoid  growths  upon  the  inflamed  surface, 
usually  the  leptothrix  buccalis.  The  differential  diagnosis  is  based  on 
the  easy  removal  and  soft  pultaceous  character  of  the  confervfe,  and  the 
appearance  under  the  microscope. 

Treatment. — Mild  cases  of  simple  pharyngitis  require  little  treat- 
ment. With  moderate  counter-irritation  over  the  throat,  and  the  use  of 
laxative  medicines,  the  inflammation  soon  subsides.  The  oleum  cam- 
phoratum  may  be  occasionally  rubbed  over  the  throat,  and  retained 
upon  it  by  flannel.  Tiie  effect  is  increased  by  the  application,  once  or 
twice  daily,  of  mustard  or  tincture  of  iodine,  or  by  adding  to  the  lini- 
ment one-fourth  or  one  third  of  its  quantity  of  turpentine. 

Some  children  seem  to  be  most  relieved  by  a  muslin  compress  fre- 
quently wrung  out  of  cool  Avater,  or  a  light  India-rubber  bag  containing 
ice.  Frequently  rubbing  the  neck  Avith  warm  oil  or  camphorated  oil, 
and  binding  upon  it  a  rind  of  salt  bacon,  are  popular  modes  of  treat- 
ment, and  no  doubt  arc  productive  of  benefit. 

In  the  severe  forms  of  this  inflammation,  occurring  independently  of 
any  other  disease,  more  acute  measures  are  sometimes  required. 

If  there  be  stupor  or  restlessness,  with  unusual  heat  of  head,  and 
starting  or  twitching  of  the  limbs  wliich  threaten  convulsions,  two  to  fivo 
grains  of  the  bromide  of  potassium  given  every  two  or  three  hours  pro- 
duce a  calmative  eflfect. 

Diaphoretics  and  sometimes  cardiac  sedatives  are  also  indicated,  such 
as  li([Uor  ammoniiie  acetatis,  s]»iritus  retheris  nitrosi,  ipecacuanha,  and 
aconite.  Medicines  of  this  kind  may  be  variously  combined  according 
to  the  age  and  condition  of  the  ])at!ent,  and  the  severity  of  the  disease. 

As  tlie  symptoms  abate,  the  intervals  between  the  doses  may  be 
increased. 

In  cases  attended  by  much  tenderness  and  dysphagia  great  relief  is 
often  obtained  by  hot  poultices  fre(|nentiy  applied  over  the  neck. 

44 


690  PERI-PIIARYNGEAL    ABSCESS. 

Topical  treatment  of  the  pliarynx  is  recommended  by  most  authors. 
Rilliet  and  Barthez  use  for  this  purpose  nitrate  of  silver  or  pow<lered 
alum.  The  former  has  been  most  employed  by  physicians.  It  may  be 
applied  in  the  proportion  of  ten  grains  to  the  ounce  two  or  three  times 
daily,  1  prefer  the  following  mixture,  used  with  the  hand  atomizer 
every  two  or  four  hours : 

R. — Acid,  carbolic .         .  ^ss. 

Potas.  chlorat.       .......  ziij. 

Glycerin;!?     ........  ^iij. 

AquiB 3vj. — Misce. 

This  can  of  course  be  used  as  a  gargle  by  those  old  enough,  or  more 
continuously  by  the  steam  atomizer. 

The  treatment  of  secondary  phar^^ngitis  will  be  described  in  connec- 
tion with  the  treatment  of  the  diseases  which  it  complicates.  Suffice  it 
here  to  say  that  this  form  of  inflammation  must  not  be  treated  by  those 
depressing  remedies  which  may  be  useful  in  cases  of  idiopathic  pharyn- 


Peri-Pharyngeal  Abscess. 

Every  practitioner  should  bear  in  mind  the  fact  that  an  abscess  occa- 
sionally forms  between  the  pharynx  and  vertebral  column  (retro-pharyn- 
geal),  or  upon  the  side  of  the  pharynx  in  the  submucous  connective 
tissue.  This  constitutes  a  disease  Avhich  is  likely  to  be  fatal,  but  which 
can  ordinai'ily  be  promptly  relieved  by  the  surgeon. 

Yet,  if  we  look  over  the  records  of  peri-pharyngcal  abscess,  we  shall 
see  that  in  a  large  proportion  of  fatal  cases  the  disease  was  supposed  to 
be  something  else,  and  so  treated  until  its  nature  was  revealed  by  post- 
mortem examination.  The  most  complete  monograph  on  this  malady 
with  which  I  am  acquainted  was  published  by  Dr.  Allen, ^  of  this  city, 
under  the  title  of  retro-pharyngeal  abscess.  To  this  paper  I  am  largely 
indebted  for  the  facts  contained  in  this  article 

Age — Cause. — This  abscess  may  occur  at  any  age,  but  it  is  most 
common  in  infancy  and  childhood.  It  is  more  frequent  in  the  first  two 
years  of  life  than  at  any  other  period.  Of  the  cases  collated  by  Dr. 
Allen,  in  which  the  age  is  stated,  twenty  were  under  ten  years,  and 
twenty-one  over  this  age.  The  abscess  occurs  in  some  patients  from 
caries  of  the  vertebral  column,  and,  in  others,  from  inflammation  de- 
veloped in  the  connective  tissue  or  small  lymphatic  glands  lying  imme- 
diately outside  the  pharynx,  or  from  a  catarrhal  pharyngitis.  Whichever 
the  cause,  there  is  usually  a  scrofulous  or  reduced  state  of  system. 

Writers  describe  two  kinds  of  peri-pharyngeal  abscess,  the  primary 
and  secondary.  This  distinction  is  based  on  the  fact,  Avhether  or  not 
the  inflammation  which  leads  to  the  abscess  be  dependent  on  an  ante- 
cedent pathological  state. 

In  the  primary  form  the  cause  is  usually  atmospheric,  or  it  is  some 
irritating  substance  which  has  been  swallowed,  and  which,  lodging  in 
the  pharynx,  produces  phlegmonous  pharyngitis. 

5  N.  Y,  Jour,  of  Med.  for  Novembor.  1851. 


ANATOMICAL    CHARACTERS.  691 

The  cause  is  mentioned  in  twenty  cases  of  the  primary  form,  collated 
by  Dr.  Allen,  as  follows :  exposure  to  cold,  ten  cases  ;  lodgement  of  bone 
in  pharynx,  eight  cases ;  blow  with  a  fencing-foil,  one  case.  In  the  last 
case  the  button  of  a  fencing- foil  passed  through  the  right  nostril  into  the 
pharynx. 

The  secondary  form  occasionally  occurs  after  measles  and  scarlet 
fever.  The  inflammation  of  the  pharynx,  common  in  those  diseases, 
extends  to  the  subjacent  connective  tissue,  and,  aided  by  the  dyscrasia 
of  the  patient,  becomes  suppurative.  Such  cases  have  been  observed  by 
Rilliet  and  Barthez.  The  most  common  cause  of  the  secondary  form  is, 
however,  caries  occurring  in  the  cervical  vertebrae. 

When  thus  occurring  it  is  similar,  both  as  regards  cause  and  nature, 
to  luinb-ir  abscess.  It  would  follow  the  same  chronic  course,  and  would 
properly  be  described  in  connection  with  it,  were  it  not  for  its  pi'oximity 
to  the  air-passages,  which  renders  the  symptoms  so  urgent  and  dan- 
gerous. In  a  few  recorded  cases  the  abscess  was  a  sequel  of  erysipelas. 
In  nineteen  cases  of  secondary  abscess,  in  Dr.  Aliens  collection,  the 
cause  is  assigned  as  follows  :  erysipelas  of  face,  two ;  inflammation  fol- 
lowing a  fall  upon  the  inferior  maxilla,  one;  after  cei-ebritis,  one; 
syphilis,  four ;  caries  of  the  cervical  vertebrie,  six ;  scrofula,  five. 

The  plausible  opinion  is  expressed  by  Mr.  Fleming,^  that  the  sup- 
puration begins,  in  a  largo  proportion  of  cases,  in  the  small  lymphatic 
glands  which  lie  in  the  connective  tissue  external  to  the  pharynx.  The 
late  Prof.  Geo.  T.  Elliot^  has  recorded  the  case  of  an  infant  of  seven 
months,  in  whom  peri-pharyngeal  abscess  immediately  followed,  and  was 
apparently  due  to  parotiditis. 

In  rare  instances  the  al)scess,  or  the  local  disease  Avhieli  leads  to  it, 
appears  to  exist  from  birth.  Thus  Dr.  E.  0.  Hockcn  relates^  the 
history  of  an  inflmtwho  died  at  the  age  of  nine  weeks.  It  had  always, 
when  taking  the  breast,  thrown  back  its  head  as  if  nearly  suffocated. 
The  walls  of  the  abscess  were  thick  and  firm,  described  by  the  writer  as 
cartilaginous.  Occasionally  there  is  no  apparent  cause  of  the  abscess, 
except  the  strumous  or  cachectic  state. 

Anatomical  Ciiaractkks. — The  seat  of  the  abscess  is  not  tlio  same 
in  all  cases.  The  swelling  can  ordinarily  be  seen  on  examining  the 
f  lUces,  but  occasionally  it  is  so  low  as  to  be  really  peri-oesophageal,  and, 
therefore,  invisible.  The  size  of  the  abscess  varies;  sometimes  it  is 
large,  pressing  inward  the  wall  of  the  pharynx  even  against  the  velum 
palati  and  into  the  posterior  nares,  if  the  abscess  have  a  high  location, 
or,  if  lower,  against  the  larynx,  so  as  to  embarrass  respiration.  Some- 
times tlic  abscess  is  so  large,  or  has  such  lateral  extension,  that  there  is 
external  swelling  along  the  side  of  the  neck.  In  a  few  cases  on  record 
the  pus,  instead  of  being  discharged  into  the  pharynx,  made  its  way 
down  the  neck  between  the  muscles  and  the  connective  tissue  to  the 
pleural  cavity,  which  it  entered,  producing  fital  pleuritis. 

The  walls  of  the  abscess  have  l)een  found  in  a  different  state  in  differ- 
ent cases.      Sometimes  the  sac,  at  the  projecting  point,  is  so  thin  that  it 

'  Dublin  .Joiirn.  of  Med.  Rci.,  vol.  xviii. 

»  Ol.'^U'i,.  Clinio,  N.  Y.,  Apploton  it  C-.,  18G8. 

'  Prov.  Med.  and  Surg.  Journ.,  1842. 


692  PERI-PHARYXGEAL    ABSCKSS. 

seems  as  if  there  might  have  been  a  spontaneous  cure,  couhl  life  have 
been  preserved  a  few  hours  longer.  In  other  cases  the  sac  is  so  thick 
and  firm  that  its  rupture,  for  many  days,  would  be  impossible. 

Symptoms. — The  percursory  symptoms  differ  in  different  cases,  ac- 
cording to  the  nature  of  the  cause,  whether  it  be  phlegmonous  pharyn- 
gitis or  simply  adenitis  or  vertebral  caries.  If  the  abscess  proceed  from 
caries,  it  is  preceded  by  deep-seatetl  pain,  greatly  increased  by  move- 
ments of  the  head,  and  probably  preceded  also  by  induration  along  the 
sides  of  the  vertebme. 

The  patient  with  this  disease  is  restless,  his  mouth  hot  and  dry  ;  tongue 
furred;  deglutition  more  or  less  difficult.  Sometimes  after  suppuration 
has  occurred  there  are  alternations  of  rigors  and  fever.  The  symptoms 
indicate  approximately  the  seat  of  the  intiammation,  but  on  examination 
we  do  not  find  that  degree  of  redness  of  the  mucous  surface  which  Ave  had 
been  led  to  expect.  The  tissues  which  are  chiefly  involved  in  the  inflam- 
mation, being  submucous,  are  hidden  from  view.  We  observe  redness  of 
the  pharynx,  but  it  is  disproportionate  to  the  intensity  of  the  symptoms. 
Some  patients  frequently  experience  a  chilly  sensation  through  the 
entire  period  of  the  abscess,  though  greater  at  one  time  than  at  another, 
and  occasionally  convulsions  occur,  especially  in  young  infants.  In 
ordinary  cases  embarrassment  of  respiration  begins  early,  and  is  the 
cause  of  the  chief  danger.  It  becomes  more  and  more  marked  as  the 
abscess  increases.  It  is  noticed  both  during  insj)iration  and  expiration. 
The  dysphagia  also  increases,  sometimes  to  such  a  degree  that  drinks 
are  taken  with  difficulty,  and  solid  food  refused.  The  resjiiratory 
s^anptoms  bear  considerable  resemblance  to  those  in  protracted  laryn- 
gitis, for  Avhich  this  disease  has  been  mistaken.  While  the  respiration 
becomes  impeded  or  whistling,  the  voice  is  also  feeble  or  indistinct, 
from  the  pressure  of  the  tumor. 

But  the  symptoms  described  above  are  not  all  present  in  every  case. 
They  vary  according  to  the  size  and  location  of  the  abscess,  Avhether  it 
be  high  or  low,  posterior  or  lateral.  I  have  met  the  disease  in  a  child 
old  enough  to  make  known  the  subjective  symptoms,  in  Avhom  there  was 
little  or  no  dysphagia,  aiid  others  report  similar  cases.  When  the 
tumor  has  attained  such  a  size  as  to  produce  Avell-marked  symptoms  and 
jeopardize  the  life  of  the  patient,  it,  or  a  part  of  it,  can  ordinarily  be 
seen  on  de])ressing  the  tongue,  but  usually  its  location  and  condition 
can  be  better  ascertained  by  exploration  with  the  finger.  The  dyspnoea 
increases  as  the  abscess  enlarges,  and,  after  a  time,  unless  it  burst  spon- 
taneously or  be  opened  by  the  surgeon,  imperfect  oxygenation  of  the 
blood  results.  In  some  patients  paroxysms  of  dyspnoea  occur,  so  as  to 
threaten  iuimediatc  suffocation ;  coughing  or  attempts  to  swallow  induce 
these  paroxysms,  and  the  ])atient  is  forced  to  remain  in  an  erect  or  semi- 
erect  posture ;  the  tongue  is  protruded,  the  head  thrown  back,  the  pulse 
is  frequent  and  rapid,  the  limbs  become  livid  and  cool,  and  finally  death 
results  from  dyspnoea.  Occasionally,  when  death  seems  inevitable,  the 
abscess  breaks  during  the  struggles  of  the  child,  and  the  patient  is 
restored  to  health.  In  rare  cases  the  result  is  different.  The  trachea 
and  bronchial  tubes  are  deluged  by  the  purulent  discharge,  ami  imme- 
diate suffocation  occurs.    The  following  was  an  example  :  In  May,  1871, 


SYMPTOMS.  693 

a  boy  two  years  and  five  montlis  old  was  brought  to  tbe  cbiss  at  Belle- 
vue,  Avlio  had  the  symptoiu-s  of  an  abscess  for  three  months.  The  head 
was  carried  on  one  side,  its  rotation  caused  pain,  and  a  laryngeal  nile 
accompanied  respiration.  The  upper  part  of  the  tumor  could  be  de- 
tected by  the  finger;  but,  on  account  of  its  low  location,  it  Avas  impos- 
sible to  open  it  -with  the  bistoury.  The  temperature  was  I0o°,  pulse 
156.  The  case  was  kept  under  observation,  but  in  a  few  days  the  dys- 
pnoea suddenly  became  so  urgent  that  death  was  imminent,  when  the 
attending  physician  of  the  class,  Dr.  Swezey,  broke  the  abscess  with  his 
finger,  and  pus  was  ejected  on  the  floor;  death,  however,  occurred 
almost  immediately. 

A  coi'rect  a])preciation  of  the  symptoms  and  nature  of  peri-pharyn- 
geal  abscess  will  be  best  obtained  by  relating  a  case.  I  select  the  fol- 
lowing from  the  Trans,  of  the  Land.  Pathol.  Soc,  Oct.  20,  1846  : 

A  female  infant  died  at  the  age  of  seven  months,  having  had  difficult 
breathing  three  weeks,  and  extreme  dyspnoea  during  the  last  days  of  life. 
The  dyspnoea  was  constant,  and  was  aggravated  by  mental  excitement, 
by  movements  of  the  body,  and  by  exposure  to  cold.  During  the  parox- 
ysms a  peculiar,  croupy  sound  accompanied  inspiration.  There  was  no 
dys|)higia  through  tlie  entire  sickness,  and  death  occurred  from  apnoea. 

The  sac  of  the  abscess  was  of  the  size  of  a  pigeon's  egg,  and  Avas  situ- 
ated between  the  upper  cervical  vertebrne  and  the  back  of  the  pharynx. 
The  abscess  was  flattened  in  front,  so  as  not  to  cause  any  decided  pro:ni- 
nence  of  the  wall  of  the  pharynx.  From  the  sac  a  second  small  cyst 
extended  forward,  forming  a  nii)])ledike  swelling  in  the  pharynx,  which 
completely  closed  the  orifice  of  the  glottis.  Its  aperture  of  communica- 
tion with  the  body  of  the  aljscess  admitted  the  point  of  tho  little  finger, 
and  the  whole  swelling  was  freely  movable  and  perfectly  translucent  at 
its  extremities  and  sides.  The  abscess  might  have  been  easily  punctured, 
with  probably  the  preservation  of  life. 

The  duration  of  this  malady  is  very  different,  according  to  the  severity 
of  the  inflammation,  the  rapidity  with  which  the  abscess  enlarges,  and 
the  direction  which  it  points.  A  lateral  or  downward  extension  is  not  so 
immediately  dangerous  to  life  as  the  anterior. 

The  time  Avhen  tlie  abscess  begins  to  form  cannot  be  precisely  ascer- 
tained, and  most  writers,  in  determining  its  duration,  compute  from  the 
first  ap])earance  of  symptoms  which  are  referable  to  the  ])liarynx.  Dr. 
J.  Byrne'  relates  a  fatal  case  in  which  the  disease  had  apparently  con- 
tinued oidy  about  one  week.  The  patient  was  an  infant  one  year  old, 
and  its  dejith  was  from  apnoea.  The  abscess  was  large,  extending  from 
the  base  of  the  skull  to  the  thorax,  and  pressing  both  on  the  larvnx  and 
trachea.  M.  I'esserer^  gives  the  history  of  an  infimt  four  niontlis  old, 
who  died  in  the  same  way  after  thirteen  days.  An  infant  nine  months 
old,  whose  case  was  published  by  Dr.  W.  C  Worthington,^  lived  nine 
days.  Tlie  abscess  occurre<l  from  exposure  to  cold;  the  jiatient  was 
treated  for  croup,  and  died  from  suffocation.  The  anterior  wall  of  tho 
abscess  was  very  thin.      Since  the  first  edition  of  this  book  Avas  published, 

>  AiiHT.  .Iniirn.  of  Mod.  Soi.,  1838. 

»  Anliiv  (i,n  do  M.nl  ,  18-JO. 

•  Prov.  Med.  and  Surg.  Joiirn.,  1842. 


OU-i  PERI -Pir  ARYXGEAL    ABSCESS. 

I  have  met  six  patients  with  tliis  disease  in  whom  the  pus  was  evacu- 
ate<l  when  the  dyspnoea  had  become  urgent.  In  two  the  symptoms  in- 
dicated a  continuance  of  the  disease  from  two  to  four  weeks,  and  in  tlie 
third  case  four  months.  Tiie  fourth  case  is  interesting  on  account  of 
the  short  duration  of  the  severe  symptoms.  The  following  is  the  record 
of  it:  ^I.  E.,  aged  7  months,  female,  nursing,  inmate  of  the  New  York 
Foundling  Asylum,  was  observ^ed  to  have  difficult  breathing  for  the  first 
time,  on  March  28,  1875.  Since  about  March  8,  some  swelling  had 
been  noticed  along  tiie  side  of  the  neck,  but  it  gave  rise  to  no  marked 
symptoms  and  she  had  not  seemed  ill,  till  the  obstruction  in  the  respira- 
tion commenced.  At  my  visit  on  the  evening  of  the  28th,  the  infant 
was  pointed  out  to  me  as  in  a  dying  condition.  She  was  lying  in  a 
state  of  stupor,  pallid,  and  gasping  for  breath,  with  a  temperature  of 
I0o°,  and  very  feeble  pulse,  numbering  about  200  per  minute.  On 
carrying  the  finger  into  tlie  throat  an  abscess  could  be  readily  detected, 
situated  in  tlie  walls  of  tlie  pharynx  on  the  left  side  posteriorly.  This 
was  easily  opened  by  a  curved  bistoury,  around  which  adhesive  plaster 
was  wound  to  Avithin  half  an  inch  of  the  point.  The  breathing  immedi- 
ately began  to  improve.  On  the  following  day  the  infant  was  playing  in 
the  mother's  lap,  with  a  pulse  of  140,  but  a  normal  temperature.  With 
the  use  of  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron,  its  health 
was  soon  fully  restored.  In  the  fiith  case  the  abscess  ruptured  by  the 
finger,  and  in  the  sixth  it  Avas  opened  by  the  lancet.  All  these  patients 
recovered. 

When  the  abscess  grows  slowly,  and  presses  lightly  on  the  air-passages, 
the  case  may  continue  for  months.  Such  a  one  was  observed  by  the  late 
Professor  Willard  Parker.  (Allin.)  This  infant  Avas  one  year  old ;  it 
sufiered  from  pharyngeal  symptoms  nine  months,  Avas  treated  for  tonsil- 
litis, and  death  occurred  as  usual  from  apnoea.  The  abscess  was  two 
inches  long,  and  there  Avas  no  disease  of  the  vertebrae.  The  same  sur- 
geon saved  the  life  of  another  patient  four  years  old.  in  Avhorn  the  dis- 
ease Avas  protracted,  by  puncturing  the  abscess;  and  Professor  Post,  of 
this  city,  also  treated  successfully  a  case  Avhich  had  continued  three 
months.     (Allin.) 

Diagnosis. — The  diagnosis  of  retro-pharyngeal  abscess  is  ordinarily 
easy,  provided  tliat  the  physician  examine  carefully  and  bear  in  mind 
the  occasional  occurrence  of  such  an  abscess.  In  a  large  proportion, 
however,  of  the  recorded  fatal  cases,  the  true  nature  of  tlie  disease  Avas 
not  recognized  during  life.  Especially  is  tlie  diagnosis  difficult  Avlien 
the  cerebro-spinal  system  is  early  implicated,  and  symptoms  arise  Avhich 
diA^ert  attention  from  the  throat  to  the  brain. 

The  maladies  for  Avhich  peri-pharyngeal  abscess  is  most  frerpiently 
mistaken  are  laryngitis  and  simple  but  severe  pharyngitis.  From 
laryngitis,  for  Avhich  it  has  been  most  frequently  mistaken,  it  may  be 
distinguished  by  the  dysphagia  and  by  the  character  of  the  initial  symp- 
toms. In  laryngitis  there  is  usually  the  peculiar  cough  from  the  first 
or  very  early,  Avhile  in  abscess  there  is  an  initial  period  of  several  days 
or  even  Aveeks  before  respiration  is  materially  affiscted.  This  is  the 
period  of  inflammation  Avhich  precedes  suppuration. 

In  abscess  pressure  of  the  larynx  backward  is  badly  tolerated,  greatly 


PROGXOSIS T  RE  ATM  EXT.  695 

increasing  the  dyspnoea,  while  in  pharyngitis  and  croup  this  effect  is  not 
so  marked.  In  abscess  the  horizont;il  position  aggravates  the  dyspnoea, 
but  not  in  pharyngitis  and  croup.  The  character  of  the  voice  also  aids 
in  diagnosticating  an  abscess  from  laryngitis,  since  in  the  former  it  is 
usually  nasal,  and  in  the  latter  hoarse  and  whispering.  But  the  decisive 
test  is  afforded  by  inspection  and  digital  exploration.  The  tumor  is  seen, 
or,  if  situated  too  low  to  be  seen,  is  felt,  upon  the  walls  of  the  pharynx. 

if  the  symptoms  of  abscess  are  masked  by  those  arising  from  the 
cerebro-spinal  system,  as  by  convulsions,  the  priority  of  the  pharyngeal 
symptoms  aids  in  determining  the  true  disease. 

In  a  case  of  suspected  abscess  the  physician  should  not  only  carefully 
inspect  the  fauces,  but  should  also  employ  digital  examination.  The 
finf^'er  will  often  detect  fluctuation  before  the  abscess  is  apparent  to  the 
eye. 

Prognosis. — With  proper  treatment  the  result  is  usually  favorable, 
but,  if  the  disease  be  not  recognized,  many  die.  In  Dr.  AUin's  cases, 
of  those  under  the  age  of  twelve  years  nine  died,  while  ten  recovered  by 
the  opening  of  the  abscess  by  the  lancet,  trocar,  or  finger,  and  one  by 
its  spontaneous  rupture.  • 

If  the  abscess  be  due  to  disease  of  the  spinal  column,  death  may  occur 
immediately  after  the  sac  is  opened,  the  caries  of  the  intervertebral  carti- 
lages producing,  according  to  Dr.  Allin,  dislocation  of  the  vertebrae. 
Death  may  also  occur,  though  rarely,  from  pleuritis,  in  consequence  of 
the  bursting  of  the  abscess  into  the  pleural  cavity.  Even  in  caries,  if 
the  sac  be  properly  opened,  and  if  need  be  reopened,  and  the  head  sup- 
ported bv  suitable  apparatus,  recovery  is  possible,  as  in  a  case  treated 
by  Prof."  Post. 

Treatment. — The  proper  treatment  of  peri-pharyngeal  abscess  is 
simple,  consisting  in  breaking  or  puncturing  the  sac  by  the  finger,  the 
lancet,  bistoury,  or  pharyngotome.  Each  method  has  been  successfully 
employed.  In  the  majority  of  cases  the  proper  Avay  to  open  the  abscess 
is  by  the  ordinary  curved  scalpel  or  liistoury,  which  should  be  covered 
by  a  strip  of  adhesive  plaster  to  within  a  half  inch  of  the  point.  If  the 
abscess  be  post-pharyngeal,  it  should  be  opened  in  the  median  line.  A 
single  incision  suffices  to  evacuate  the  pus.  If  the  abscess  point  or  be 
elastic,  there  is  little  danger  of  wounding  any  important  vessel,  or  pro- 
ducing dangerous  hemorriiage  if  tlie  operation  be  properly  performed. 
It  may  be  necessary  to  open  the  abscess  more  than  once,  as  in  a  case 
reported  by  Dr.  Post,  and  another  which  I  saw  with  Dr.  Livingston,  of 
this  city.  In  certain  cases,  when  the  knife  cannot  be  readily  eini)loyed, 
the  abscess  may  be  opened  by  pressure  with  the  finger-nail  or  the  edge 
of  a  teaspoon. 

Patients  with  this  disease  ordinarily  require  constitutional  treatment, 
especially  the  use  of  tonics,  ferruginous  and  vegetable.  The  citrate  of 
iron  and  quinine,  the  citrate  of  iron  and  ammonium,  and  in  strumous 
cases  the  svrup  of  the  iodide  of  iron  with  cod-liver  oil,  are  eligible  ])re- 
parations.     Nutritious  diet  and  often  alcoholic  stimulants  are  required. 


696  OESOPHAGITIS. 


CEsophagitis. 

Disease  of  tlie  oesophagus  in  infancy  and  childhood  is  comparatively 
rare,  intiammation  being  the  most  fiwjuent  affection  of  this  portion  of 
the  digestive  tube  in  these  periods,  and,  indeed,  the  only  one  Avhich 
claims  attention.  It  is  most  common  in  infants  under  the  age  of  three 
or  four  months,  who  are  deprived  of  the  breast-milk,  and  are  given  a 
diet  -which  is  -with  difficulty  digested,  and  perhaps  taken  too  hot  or  too 
cold.  It  is,  therefore,  most  common  in  foundling  hospitals.  I  have  fre- 
quently observed  it  in  the  Infant's  Hospital,  and  the  Nursery  and 
Ohilds  Hospital,  of  this  city,  chiefly  at  the  autopsies  of  bottle-fed 
infants  under  the  age  of  six  months,  whose  symptoms  had  indicated 
disease  or  derangement  of  the  digestive  function.  Many"  of  them  had 
diarrhoea,  and  died  in  a  state  of  emaciation.  OEsophagitis  in  these  cases 
was  associated  with  simple  or  gangrenous  stomatitis,  thrush,  or  with 
gastritis  or  entero-colitis.  Sometimes  all  these  inflammations  coexisted. 
In  a  few  cases  the  confervoid  growth  of  thrush  had  extended  from  the 
mouth  to  the  oesophagus.  It  occurred  in  small  hemispherical  masses, 
scarcely  as  large  as  a  pin's  head.  Swallowing  corrosive  or  strongly 
irritating  substances,  as  the  acids  or  alkalies,  is  an  occasional  cause 
of  oesophagitis,  the  irritant  at  the  same  time  producing  stomatitis  and 
gastritis. 

Anatomical  Characters. — The  inflamed  surfixce  sometimes  presents 
a  uniformly  injected  appearance.  Usually,  however,  there  is  greater 
intensity  of  the  inflammation  in  streaks  or  patches  than  over  the  surface 
generally.  I  have  frequently  observed  at  autopsies  a  greater  degree  of 
inflammation  in  the  lower  than  upper  half  of  the  oeso})hagus,  even  when 
the  infant  had  stomatitis  at  the  time  of  death. 

OEsophagitis  occurring  from  faulty  regimen  or  anti-hygienic  condi- 
tions is  not  accompanied  by  as  much  thickening  of  the  walls  of  the  tube 
as  often  occurs  in  some  other  portions  of  the  digestive  canal,  as,  for  ex- 
ample, in  the  colon.  Diphtheritic  inflammation  of  the  oesophagus  is 
accompanied  by  so  great  infiltration  of  the  mucous  membrane  and 
underlying  connective  tissue  that  I  have  seen  the  oesophageal  walls 
three  or  four  times  the  normal  thickness. 

Occasionally  ulcerations  of  the  oesophageal  mucous  membrane  are  ob- 
served in  the  lower  part  of  the  tube,  and  Billard  describes  the  ulcerative 
form  of  ocso])hagitis.  xVt  the  first  autopsies  at  which  I  observed  these 
ulcers,  I  supposed  that  they  were  pathological,  and  indicated  a  severe 
grade  of  inliammation  ;  but  a  more  extended  observation  has  convinced 
me  that  they  are  usually  post-mortem,  and  are  not  at  all  dependent  on 
inflammation  of  the  oesophagus.  The  solvent  power  of  the  gastric  juice 
not  only  causes  ulceration  in  the  stomach,  but  entering  the  oesophagus 
may  and  riot  infre(|uently  does  produce  a  solvent  action  on  the  mucous 
tissue  there.  At  the  meeting  of  the  London  Pathological  Society, 
March  4,  1852,  Dr.  Graily  Hewitt  presented  a  s])ecimen  in  which  the 
gastric  juice  had  not  only  eaten  entirely  through  the  coats  of  the  oesoph- 
agus an  inch  above  the  stomach,  but  had  even  attacked  the  left  lung. 
()ver  the  age  of  six  months  inflammation  of  the  oesophagus  is  rare. 


IXDIGESTIOX.  697 

The  symptoms  of  oesophagitis,  in  young  and  emaciated  infants,  in 
wliom  it  ordinarily  occurs,  are  not  well  pronounced.  Pain  in  deglutition, 
or  tenderness  on  pressure  over  the  oesophagus,  if  present  in  these  infants, 
is  ordinarily  not  appreciable,  nor  have  they  seemed  to  me  to  vomit  oftener 
than  other  infants  of  this  class  who  suffered  from  indigestion  and  gastro- 
enteritis, without  oesophagitis.  It  is,  therefore,  difficult  to  diagnosticate 
oesophagitis  in  them.  It  is,  according  to  my  ol)servation,  oftener  present 
than  absent  in  spoon-fed  inflmts  of  three  months  or  under  who  have  per- 
sistent stomatitis  and  entero-colitis. 

Treatment. — In  the  oesophagitis  of  foundlings  and  ill-nourished  in- 
fants, which  arises,  as  has  been  stated,  from  faulty  regimen,  no  treatment 
is  re(juired  apart  from  that  designed  to  relieve  the  stomatitis  or  entero- 
colitis with  which  it  occurs.  Attention  must  be  directed  mainly  to  the 
diet  and  liygienic  management.  The  remedial  measures  proper  for 
such  patients  are  more  fully  detailed  in  our  remarks  on  entero-colitis. 
(Esophagitis  produced  by  swallowing  corrosive  or  highly  irritating  sub- 
stances requires  the  same  treatment  as  in  the  adult,  to  wit,  poultices, 
demulcent  drinks,  etc. 


CHAPTER    YI. 

INDIGESTION,  CONGESTION  OF  STOMACH,  GASTRITIS,  FOLLIC- 
ULAR GASTRITIS,  DIPHTHERITIC  GASTRITIS,  POST-MORTEM 
DIGESTION,  SOFTENING. 

Indigestion  is  more  common  during  infancy  than  in  any  other 
period  of  life.  While  the  digestive  organs  in  the  adult  readily  assimi- 
late a  great  variety  of  food,  it  is  necessary  for  the  well-being  of  the 
infant  that  its  diet  be  simple  and  carefully  prepared.  Departure  from 
this  rule  leads  to  indigestion  and  ulterior  diseases. 

After  the  age  of  two  years  a  mixed  diet  is  readily  assimilated,  the 
digestive  function  less  fre(|uently  disordered,  and  indigestion  presents 
few  peculiarities  to  distinguish  it  from  that  of  the  adult. 

Indigestion  in  some  children  is  habitual ;  in  others  the  digestive  pro- 
cess is  ordinarily  well  performed,  but,  from  some  temporary  derange- 
ment of  system  or  error  of  diet,  an  acute  attack  of  indigestion  occurs. 
Hence,  two  forms  of  this  ailment  may  be  described:  first  acute,  refer- 
ring to  temporary  attacks;  secondly,  chronic,  referring  to  the  habitual 
state. 

Causes. — The  causes  of  indigestion  arctwofold:  first,  the  condition 
of  the  digestive  function  intle|)endently  of  the  aliment ;  secondly,  the 
unwholesome  or  improper  character  of  the  ingesta.  Anything  which 
lowers  the  vital  })owers  may  be  a  predisposing  cause  of  indigestion,  by 
impairing  the  function  of  the  organs  which  assimilate  the  fooil.     Impure 


698  INDIGESTION. 

air  and  personal  uncleanliness,  protracted  liot  weather,  and  previous  dis- 
ease, are,  among  the  common  predisposing  causes.  The  strong  country 
child  can  thrive  upon  a  diet  which,  given  to  the  more  feebh'  (jhild  of  the 
city,  wouhl  produce  a  deleterious  results.  During  the  summer  months 
it  often  haj)pens  that  an  infant  in  the  city  cannot  digest  properly  any 
food  given  to  it  except  the  mother's  milk  ;  and  from  this  results  much  of 
the  infontile  sickness  and  mortality  which  make  this  season  of  the  year 
much  dreaded  by  parents.  There  is  a  natural  difference  in  children,  as 
regards  liability  to  disordered  digestion.  Some  do  well  upon  a  diet 
Avhicli  given  to  others  similarly  situated  occasions  vomitinsr,  ffastralgia, 
and  ilatulence. 

In  the  majority  of  cases  of  indigestion,  however,  the  fault  does  not 
exist  in  the  child.  It  is  fed  too  often  or  irregularly,  or  upon  a  diet  that 
is  unwholesome  or  indigestible.  It  is  well  known  that  the  miik  of  the 
mother  or  the  wet-nurse  is  liable  to  clumges  which  render  it  for  the 
time  unsuitable  for  the  infant.  Her  food  may  be  of  such  a  quality,  or 
her  mind  so  excited,  or  some  function  of  her  system  so  disordered,  as 
to  effect  a  temporary  change  in  the  constitution  of  the  milk.  The  oc- 
currence of  the  catamenia,  or  of  gestation,  in  mothers  who  are  suckling, 
not  infre(iuently  produces  this  unfavorable  result. 

Indigestion  is  most  common  in  those  infants  who,  deprived  of  the 
mother's  milk,  are  intrusted  to  wet-nurses,  or  fed  from  the  bottle.  The 
milk  of  the  wet-nurse,  from  not  agreeing  with  the  age  of  the  infant, 
from  irregularity  in  her  mode  of  life,  from  the  acescent  nature  of  her 
food,  or  from  other  causes  which  are  not  appreciable,  may  disagree  with 
the  infant,  and  be  imperfectly  digested. 

The  most  common  cause  of  indigestion  in  the  infiint  is  artificial  feed- 
ing. This,  in  the  cities,  is  productive  of  a  great  amount  of  gastric  and 
intestinal  derangement  and  disease.  The  younger  the  infant,  the  less 
frequently  does  it  thrive  if  brought  up  by  hand. 

Whatever  care  may  be  bestowed  in  the  preparation  of  its  food, 
whether  cow's  or  goat's  milk,  or  farinaceous  substances  be  used,  there 
is  seldom  that  healthy  nutrition  whicli  is  observed  in  infants  wlio  receive 
the  breast-milk.  The  ''swill  milk"  in  common  use  among  the  ])Oor 
families  of  this  city  is  totally  unfit  for  the  feeding  of  infants,  and  is  apt 
to  cause  flatulence,  acidity,  and  indigestion.  Acute  indigestion  occurs 
in  children  of  any  age  from  food  unsuitable  in  quality  or  quantity,  which 
produces  gastralgia  and  otlier  symptoms  to  be  detailed  hereafter.  Those 
who  suffer  habitually  from  malassimilation  are  especially  liable  to  such 
acute  attacks. 

In  the  period  of  cliildhood,  chronic  indigestion  is  much  less  frequent 
than  in  infancy,  but  children  are,  perhaps,  more  subject  tlian  infants 
to  the  acute  form.  Tliis  is  induced  by  ingesta  taken  in  too  large  quan- 
tity, or  of  a  kind  Avhich  is  Avith  difficulty  digested.  Cherries,  currants, 
raisins,  and  the  parenchyma  of  oranges  and  lemons,  dried  fruits,  and 
confectionery,  whicli  are  so  often  heedlessly  given  to  children,  are  com- 
mon causes  of  acute  attacks  of  indigestion.  These  substances,  being 
but  partially  digested  or  not  at  all,  and  sometimes  accumulating  for  days 
in  the  stomach  or  intestines,  may  lead  to  a  very  serious  and  dangerous 
condition. 


SYMPTOMS.  699 

Symptoms. — Before  describing  the  symptoms  of  indigestion  I  wish 
to  direct  attention  to  one  form  of  vomiting  in  young  infants  which  is 
usu-iliy  attributed  to  indigestion  by  the  young  practitioner,  but  which 
really  has  no  pathological  significance.  I  refer  to  vomiting  or  regurgi- 
tation of  milk  in  hearty  and  well-nourished  infants,  resulting  from  too 
frequent  nursing  or  over-nursing.  It  occurs  without  previous  nausea, 
and  with  little  effort.  The  relatively  small  size  of  the  stomach  in  young 
infants,  its  position  more  vertical  than  in  older  children,  and  the  little 
development  of  the  fundus,  which  is  the  proper  receptacle  of  the  milk, 
favor  this  regui'gitation.  The  milk  that  is  ejected  is  unchanged  if  it 
be  returned  immediately  after  the  nursing,  but  if  some  moments  have 
elapsed  the  casein  is  more  or  less  coagulated.  Little  harm  is  done  by 
this  loss  of  nutriment,  if  the  infant  appear  well  and  thriving.  It  is, 
indeed,  salutary,  for  if  the  food,  that  is  in  excess  of  what  is  wanted,  and 
in  excess  of  what  can  be  digested,  be  retained,  it  undergoes  fermenta- 
tion, and  becoming  an  irritant  causes  indigestion  and  diarrhoea.  The 
remedy  consists  in  less  freipient  or  less  prolonged  nursing,  and  allowing 
the  infant  to  lie  quietly  in  the  crib  after  each  nursing. 

But  vomiting  is  a  symptom  that  should  always  arrest  attention,  and 
its  cause  be  ascertained.  If  the  child  cease  to  grow,  and  lose  its  vivacity, 
the  vomiting  has  pathological  significance.  Frequent  vomiting,  without 
other  marked  symptoms  referable  to  the  digestive  apparatus,  and  with 
evident  loss  of  fiesh  and  strength,  is,  in  most  cases,  a  symptom  of  gastric 
indigestion,  or  of  incipient  meningitis.  The  presence  of  mucus  in  the 
ejected  matter,  eructation  of  g;is,  and  the  apparent  absence  of  headache, 
and  of  other  meningeal  symptoms,  apart  from  the  vomiting,  aid  in  estab' 
lishing  the  diagnosis  of  gastric  indigestion. 

With  these  preliminary  remarks,  we  will  proceed  to  consider  the 
symptoms,  first,  of  habitual,  and  next,  of  acute  temporary  indigestion. 

The  nursiusr  infant,  if  the  milk  continually  disagree  with  it,  is  fret- 
ful.  It  has  a  discontented  aspect ;  it  seldom  smiles,  and  is  not  amused 
by  pliythings,  or  is  only  amused  for  a  short  time.  Its  features  are 
pallid,  and  bear  the  appearance  of  faulty  nutrition.  Its  body  and  limbs 
are  more  or  less  wasted,  or  are  soft  and  flabby.  Vomiting  is  frecpiently 
present,  and  sometimes  a  large  mass  or  masses  of  casein  are  ejecte<l, 
which  have  evidently  lain  a  considerable  time  in  the  stomach.  The 
bowels  may  be  constipated  or  loose,  and  the  evacuations  are  unhealthy. 
This  state  of  the  infant  continuing  prevents  the  necessary  rest  of  the 
mother,  and  may  affect  unfavorably  her  health,  so  as  to  reduce  the  quan- 
tity of  her  milk,  or  render  it  still  more  unwholesome. 

In  habitual  indigestion  of  young  children  fermentation  of  the  food 
occurs  to  a  great  extent,  instead  of  normal  digestion,  and  the  feruuMi- 
tation  results  in  the  production  of  acids.  Whatever  irritates  the  gastro- 
intestinal surface,  causes  an  increased  secretion  of  mucus,  and  it  is 
believed  that  the  mucus,  since  it  is  alkaline,  prevents  to  a  great  extent 
the  digestive  action  of  the  pepsin,  which  requires  an  acid  medium,  so 
that  l.Kttic,  butyric,  and  the  fatty  acids  result.  This  acid  fermentation 
beginning  in  the  stomach,  extends  to  the  intestines  as  tlu^f^od  is  carried 
downward.      Hence  the  acid  breath,  sour-suielling  cjecta,  fetid  stools, 


700  INDIGESTION. 

flatulence  and  colicky  pains,  indicating  both  gastric  and  intestinal  dys- 
pepsia, so  common  in  young  improperly  fed  infants. 

Habitual  indig'^stion  is,  as  might  be  expected,  more  common  and 
severe  in  artificially  fed  infants,  than  in  those  at  the  breast,  and  it 
is  more  likely  to  result  in  gasti'o-intestinal  catarrh.  In  rural  localities 
Avhere  children  are  much  of  the  time  in  the  open  air,  have  good  consti- 
tutions, active  digestion,  and  fresh  food,  dyspepsia  is  comjjaratively  rare, 
but  in  large  cities,  in  which  the  conditions  of  life  are  so  different,  its 
occurrence  is  common.  Gross  carelessness  in  the  feeding,  and  ignor- 
ance on  the  })art  of  mothers  of  the  dietetic  requirements  of  young  chil- 
dren, contribute  greatly  to  its  frequency. 

Attacks  of  acute  indir/cstiou  not  infre(juently  occur  from  careless  and 
improper  feeding,  in  children  -who  are  habitually  dyspeptic,  as  -well  as  in 
those  Aviiose  digestive  function  is  usually  Avell  performed,  in  these  acute 
attacks  young  children,  especially  infants,  often  suffer  much  from  colicky 
pains,  gastralgia  or  enteralgia.  Their  countenance  indicates  suffering, 
they  utter  sharp  cries;  their  thighs  are  flexed  over  the  abdomen,  and 
moved  from  side  to  side.  Warm  si)irituous  lotions,  friction  or  gentle 
pressure  upon  the  abdomen,  gives  some  relief,  especially  if  it  be  attended 
by  the  expulsion  of  flatus.  Vomiting,  or  an  evacuation  of  the  bowels, 
commonly  removes  the  offending  substance,  and  the  pain  subsides. 

Attacks  of  acute  indigestion  come  on  suddenly,  and  occasionally  are 
so  severe  thai  they  produce  dangerous  symptoms,  as  eclampsia.  Ajjart 
from  pain,  or  a  sensation  of  weight  or  fulness  in  the  abdomen,  symp- 
toms of  a  reflex  character  frequently  occur,  such  as  headache,  drowsiness 
or  languor,  sudden  twitching  of  the  limbs  premonitory  of  convulsions, 
and  even  severe  or  repeated  convulsions.  One  of  the  most  severe 
attacks  of  eclampsia  which  I  have  seen,  occurred  in  a  boy  of  eight  or 
ten  years,  induced  by  swallowing  the  pulp  of  oranges,  which  he  had  been 
in  the  habit  of  eating,  and  which  had  accumulated  in  the  stomach  and 
intestines.  The  expulsion  of  the  offending  substance  gave  immediate 
relief.  In  some  children  with  acute  indigestion,  the  pulse  is  notably 
accelerated,  the  fece  flushed,  the  surface  hot,  and  the  temperature  ele- 
vated two  or  three  degrees  above  normal. 

As  the  child  advances  in  years,  and  becomes  strongei",  its  digestive 
function  is  more  active,  a  greater  variety  of  food  can  be  assimilated,  and 
indigestion,  whether  temporary  or  habitual,  is  less  frequent  than  in  the 
first  years  of  life. 

Prognosis. — Indigestion  in  the  adult,  when  not  due  to  organic  dis- 
ease, involves  little  danger  to  life,  but  in  infancy  its  conse(juences  are 
often  serious.  Habitual  indigestion  in  the  infant,  whether  due  to  the 
bad  quality  of  the  breast-milk,  or  to  artificial  feeding,  is  liable  to  cause 
inflammation  of  the  buccal,  oesophageal,  gastric,  or  intestinal  mucous 
membrane,  and,  in  some  patients,  of  two  or  more  of  these  divisions  of 
the  intestinal  tract.  Thus,  especially  in  the  warm  months,  the  acid 
products  of  indigestion  often  cause  a  dangerous  catarrhal  infiamniation, 
acconqjanied  by  vomiting  and  frequent  stools.  Many  cases  of  atr()|)hy 
in  infants,  characterized  by  arrested  growth  and  gradual  loss  of  flesh 
and  strength,  till,  perhaps,  the  features  have  a  sunken  and  senile  ap- 
pearance from  the  waste,  and  the  skin  lies  in  Avrinkles,  originate  in 


DIAGNOSIS TREATMENT.  701 

habitual  indigestion.  Henoch  points  out  the  frequency  of  gastro- 
malacia  in  infants  who  have  suifered  from  severe  indigestion  accompa- 
nied by  the  abundant  production  of  acids.  The  softening  of  the  stomach 
is  believed  to  be  largely,  if  not  entirely,  cadaveric,  the  result  of  post- 
mortem digestion,  from  the  presence  of  pepsin  and  the  acids  of  fer- 
mentation. Tiie  gastric  mucous  membrane  can  be  readily  scraped  away 
by  the  nail,  and  it  presents  a  gelatiniform  appearance.  Sometimes  even 
the  stomach  is  perforated,  and  the  adjacent  organs  are  acted  on  by  the 
corrosive  liquids. 

If  the  dyspepsia  have  not  continued  so  long  as  to  cause  inflammatory 
complications,  prompt  recovery  is  prolxible  by  the  use  of  suitable  food 
and  corrective  medicines.  If  such  complications  be  present,  recovery 
can  only  be  gradual. 

Diagnosis. — Habitual  indigestion  does  not  usually  continue  long 
without  the  occurrence  of  more  or  less  gastro-intestinal  catarrh.  The 
poor  nutrition  and  appetite,  the  unhealthy,  flatulent  stools,  containing 
mucus,  the  vomiting,  and  occasional  colicky  pains,  are  symptoms  which 
plainly  indicate  a  dyspeptic  origin.  Attacks  of  acute  indigestion  are 
also  easily  diagnosticate/1,  in  most  instances,  by  the  sudden  occurrence 
of  the  symptoms,  such  as  vomiting,  pain  in  tlie  abdomen,  or  a  sensation  of 
fulness,  eructation  of  gas,  etc.,  and  the  speedy  subsidence  of  symptoms 
when  the  cause  is  removed.  But  sometimes,  especially  in  children  over 
the  age  of  two  or  three  years,  the  symptoms  may  so  closely  resemble 
those  of  other  acute  diseases,  that  a  careful' examination  is  required  in 
order  to  make  a  clear  and  correct  discrimination.  Thus  I  have  related 
above  the  history  of  a  case  in  which  the  febrile  movement  and  expira- 
tory moan  closely  resembled  those  of  pneumonia,  but  the  symptoms 
quickly  abated  on  the  expulsion  of  a  considerable  quantity  of  orange- 
pulp.  An  attack  of  acute  indigestion,  attended  by  vomiting,  rapid 
pulse,  elevated  temperature,  with  jtcrhaps  some  erythema,  may  be  mis- 
taken for  the  commencement  of  one  of  the  febrile  diseases  to  which  chil- 
dren are  so  liable.  If,  on  examination  of  tlie  fauces,  no  redness  of  the 
throat  be  observed,  scarlet  fever  and  diphtheria  can  be  excluded.  By  a 
free  evacuation  of  the  boAvels,  the  symptoms  abate,  and  the  attack  ends, 
so  that  if  there  were  any  doubt  in  the  diagnosis  it  is  soon  dispelled. 

"When  eclampsia  results  from  an  attack  of  acute  indigestion,  the 
physician  is  often  compelled  to  act  promptly  without  a  clear  diagnosis, 
but  the  result  of  treatment  soon  renders  the  nature  of  the  attack 
apparent. 

Treatmext. — The  first  indication  in  treatment  is  obviously  the  re- 
moval of  the  cause.  In  nniite  indigestion,  when  there  is  reason  to 
believe  that  there  is  some  olTcnding  substance  in  the  stomach  or  intes- 
tines, if  the  symptoms  occur  soon  after  tlie  substance  is  taken,  an  emetic 
may  be  administered,  and  ipecacuanha,  in  syrup  or  ])owder,  is  a  safe 
and  usually  efficient  remedy.  If  several  hours  have  elapsed  a"  purgative 
should  be  f^iven,  as  castor  oil,  cither  alone  or  in  combination  Avith  svrup 
of  rhubarb. 

If  the  symptoms  be  urgent,  especially  if  convulsions  be  threatened, 
we  should  not  wait  for  the  slow  action  nf  a  purgative,  but  should  resort 
to  enemata  to  open  the  bowels.     Sometimes  the  pain   in  acute  indiges- 


702  INDIGESTION. 

tion  is  such  as  to  require  the  use  of  opiiites.  In  the  infant  there  is  often 
an  excess  of  acid  in  the  stomach  and  intestines,  Avhich  is  best  treated  by 
alkaline  remedies,  as  lime-water  in  combination  -with  the  opiate.  The 
following  mixture  Avill  be  found  useful  in  such  cases: 

B. — Tinct.  opii  denclorat.,  or  li(j.  opii  composit.   (Squibbs)         .     gtt.  xij. 

Magiie*.  calc'inat.         ........     pr.  xij— xxiv. 

Saccli.  alb.  .  .         .         .         .         .         .         .         .      ^j. 

Aq.  anisi o '*®- — -Misce. 

Dose,  the  bot'lo  beinsi;  first  shaken,  one  teaspoonful  every  two  hours  to  a  child  a 
year  olJ,  until  relief.  If  there  be  much  pain,  it  is  well  to  add  a  litlle  chloroform 
or  Hoft'nuin's  anodyne  to  the  mixture. 

Or  the  following  mixture  : 

R. — Tinct.  opii  deodorat.,  or  liq.  opii  composit.  .         .         .  git.  xij. 

Bismuth,  subcarbonat.  .......  ^iss. 

Syr.  simplic.  .........      5s3. — Misce. 

Aq.  cinnamomi     .........      ^j. 

Shalve  bottle  thoroughly  and  give  one  teaspoonful. 

If  in  the  acute  indigestion  of  infimts  diarrhoea  occur,  the  camphorated 
tincture  of  opium,  in  combination  with  chalk  mixture,  may  be  given, 
fifteen  drops  of  the  one  to  a  teaspoonful  of  the  other,  or  the  above  mix- 
ture. Infimts,  whose  diet  consists  largely  of  cow's  or  goat's  milk, 
digest  with  most  difficulty  the  casein,  which  often  passes  the  bowels  in 
an  imperfectly  digested  state,  or  it  collects  in  a  large  and  firm  mass  in 
the  stomach,  causing  gastralgia  and  rendering  the  child  fretful  till  it  is 
vomited.  I  have  elsewhere  recommended,  as  important  to  prevent  these 
attacks  of  acute  dyspepsia,  the  use  of  the  upper  third  of  the  milk,  which 
contains  less  than  the  average  casein,  and  the  addition  of  an  alkali  to 
the  milk,  which  retards  coagulation  till  it  begins  to  be  acted  upon  by 
the  gastric  juice,  and  tends  to  prevent  the  foriuation  of  large  and  firm 
caseous  coagula  in  the  stomach.  The  addition  of  a  little  farinaceous 
food,  as  barley  water  to  the  nursing-bottle,  will  sometimes  produce  the 
same  effect  by  mechanically  separating  the  particles  of  milk.  Pep- 
tonized milk,  as  recommended  in  our  remarks  on  the  hygienic  treatment 
of  intestinal  catarrh,  Avill  also  be  found  useful  in  certain  cases. 

In  chronic  indigestion  the  means  of  relief  are  different.  They  are 
twofold:  first,  as  regards  change  of  diet ;  secondly,  measures  to  improve 
the  digestive  function.  Spoon-fed  infiints,  suffering  from  habitual  in- 
digestion, require  the  utmost  care  as  regards  the  character  of  their  food, 
its  preparation,  and  the  times  of  feeding.  Often  it  is  best,  if  practica- 
ble, to  procure  a  wet-nurse,  and  sometimes  removal  to  a  more  salubri- 
ous locality  is  followed  at  once  by  improvement  in  the  digestive  function. 
If  the  infant  be  already  wet-nursed,  the  milk  should  bo  examined 
microscopically  and  otherwise,  and  inquiry  should  be  instituted  in  refer- 
ence to  the  health  and  diet  of  the  Avet-nurse.  Sometimes  a  change  of 
wet-nurse  is  advisable.  For  facts  and  considerations  bearing  on  this 
point  the  reader  is  referred  to  the  chapters  relating  to  regimen. 

Children  with  chronic  indigestion  are  occasionally  much  benefited  by 
the  moderate  and  judicious  use  of  alcoholic  stimulants.  They  should  be 
given  sparingly  with  their  food,  and  should  be  discontinued  as  soon  as 


TREATMEXT.  703 

the  digestive  function  is  full}^  restored.  ]M.  Donne  and  some  other 
French  writers  recommend  the  habitual  use  of  wine  for  infants  even  in 
a  state  of  health,  but  there  are  reasons,  moral  as  well  as  physical,  why 
alcoholic  stimulants  should  only  be  used  as  medicines,  and  not  in  a  state 
of  health. 

If  the  case  be  one  of  simple  or  uncomplicated  indigestion,  pepsin  or 
lactopeptin  of  the  shops  and  tonics  may  be  employed.  In  many  in- 
stances, however,  especially  in  infancy,  gastro-intestinal  inflammation 
has  supervened,  and  in  such  cases  those  remedies  should  be  employed 
which  exert  a  favorable,  or,  at  least,  not  an  unflivorable  effect  on  the 
inflamed  surface  over  which  they  pass. 

In  habitual  indigestion  remedies  are  obviously  required  which  in- 
crease tlie  quantity  of  the  digestive  ferments.  The  following  Avill  be 
found  a  useful  prescription  in  cases  of  indigestion  in  which  gastro- 
intestinal catarrh  has  supervened : 

R. — Acidi  hydrochlorici  diliit.  .         ....     ptt.  xvj-xxxij. 

Lacto-peptiiii  or  pepsini     .....      ^j. 

Bismuth,  subnitrat ^ij. 

S\'r.  siniplic.        .         .         .         .         .         .         .      t^fs. 

Aqua3  destillat.  •.         ......      511J. — Misce. 

Sliake  bottle,  and  give  one  teaspoonful  before  each  feeding. 

If  the  stools  continue  frotliy  and  offensive  on  account  of  the  fermenta- 
tion, the  following  Avill  be  found  beneficial : 

R. — Crea?oti  or  acidi  carbolic!    .....  gtt.  ij  to  iv. 

Syr.  simplic.         .         .         .         .         .         .         .  5-s. 

Aquse  destillat.     .......  5J^s. — Misce. 

Dose,  one  teaspoonful  every  two  hours. 

In  children  over  the  age  of  three  or  four  years,  the  vegetable  tonics 
are  often  useful,  as  quinine  in  half-grain  or  one-grain  doses,  and  the 
elixir  of  calisaya  bark.  Iron  may  also  be  given,  especially  the  milder 
preparations,  as  the  citrate  in  anremic  cases. 

Among  the  useful  vegetable  stomachics  and  tonics  may  also  be  men- 
tioned the  comjjound  tincture  of  cinchona,  com])ound  tincture  of  gen- 
tian, infusion  of  columbo,  fluid  extract  of  columbo,  and  fluid  extract  of 
cinchoiui. 

If  ciironic  indigestion  be  complicated  with  gastro-intestinal  inflamma- 
tion, subacute  or  chronic,  for  this  is  the  form  which  is  usually  present, 
there  are  still  certain  tonics  which  may  be  advantageously  administered. 
Columbo  an<l  the  comnound  tincture  of  cinchona  are  often  useful  in  these 
cases,  and  of  the  cluilybeates  wine  of  iron  or  the  citrate  of  iron  and 
ammonium  or  the  licpior  ferri  nitratis  may  be  safely  administered.  In 
most  cases,  hov/ever,  change  in  the  diet  properly  made  will  be  fouiul 
more  useful  than  tonic  and  corrective  medicines. 

Infants  affected  with  diarrhoea  from  indigestion  often  improve  under 
the  use  of  powders  consisting  of  ecpial  ])arts  of  suluiitratc  of  bismuth  and 
pepsin  or  lactopej)tin.  An  infant  of  three  months  can  take  three  grains 
of  each  every  three  hours,  or  before  each  feeding. 

Dyspepsia  often  rapidly  disappears  by  hygienic  measures  without  the 
use  of  medicines,  as  by  removal  from  the  city  to  the  country,  outdoor 


704  GASTRITIS. 

exercise,  or,  if  tlioputient  be  an  infiint,  b)'  being  carried  into  the  open  air 
daily.  In  infants,  also,  marked  improvement  is  often  observed  on  the 
approacli  of  the  cool  and  bracing  weather  of  autumn  and  "winter. 


Congestion  of  the  Stomach. 

Passive  congestion  of  tlie  stomach  is  described  among  the  diseases  of 
this  organ  by  Billard ;  but  it  is  a  pathological  state  of  little  importance 
in  itself.  It  occurs  in  ncAvborn  infonts,  asphyxiated  at  birth  and  with 
difficulty  resuscitated.  In  these  cases  there  is  generally  intense  capil- 
lary congestion  throughout  the  system.  The  mucous  membrane  of  the 
stomach  is  injected,  but  not  more  than  that  of  the  mouth  or  intestines. 
If  circulation  and  respiration  be  fully  esta])lished,  this  injection  of  tlie 
capillaries  subsides.  No  treatment  is  required,  except  measures  to  pro- 
mote the  circulatory  and  respiratory  functions.  In  cyanosis  and  atelec- 
tasis there  is  often  general  congestion  of  the  capillaries  of  the  systemic 
circulatory  system,  on  account  of  the  obstruction  to  the  flow  of  blood 
through  the  heart  in  the  one  disease  and  through  the  lungs  in  the  other. 
There  is  in  these  cases  passive  congestion  of  the  stomach,  ])ut  not  more 
than  of  other  organs. 

Gastritis. 

Inflammation  of  the  stomach,  except  when  produced  by  the  direct 
contact  of  some  irritant,  is  rare  in  infancy  and  childhood,  independently 
of  disease  in  some  other  portion  of  the  intestinal  tract.  Cases  have, 
however,  been  reported  in  which  it  was  not  known  that  any  irritating 
ingesta  had  been  taken,  and  in  which  a  careful  examination  revealed  a 
healthy  or  nearly  healthy  state  of  other  portions  of  the  digestive  tube. 
The  subjects  were,  for  the  most  })art,  young  infants.  The  following  is 
an  example  related  by  Biilard : 

An  infant,  four  days  old,  remarkable  for  the  color  of  his  face  and 
firmness  of  flesh,  refused  the  breast,  and  vomited  yellow,  acid  matter. 
On  the  following  day  the  vomiting  had  increased,  the  legs  were  oedcma- 
tous,  face  pallid  and  pinched,  respiration  difficult,  skin  cold,  pulse  slow 
and  irregular,  and  pressure  on  the  epigastric  region  produced  cries  indic- 
ative of  pain. 

Third  day  :  general  sinking  ;  fiice  thin  and  expressive  of  great  pain  ; 
stools  natural. 

Fourth  and  fifth  days  :  condition  the  same.  D^jath  occurred  on  the 
sixth  day ;  and  the  autopsy  was  made  on  the  day  following. 

With  the  exception  of  slight  pneumonitis,  no  disease  was  discovered 
in  any  part  of  the  system  beside  the  stomach.  The  mucous  membrane 
of  this  organ  was  intensely  vascular  near  the  cardiac  orifice  and  along 
the  lesser  curvature.  This  part  was  also  tumefied,  and  could  be  easily 
raised  Avith  the  finger-nail.  The  remainder  of  the  gastric  surface  was 
hyperremic,  but  to  a  less  extent. 

This  case  is  interesting  as  showing  wliat  may  happen,  though  rarely. 
A  nursing  infant  is  seized  with  gastritis  without  apparently  having  taken 


AGE.  705 

any  irritating  ingesta,  and  without  other  disease  of  the  digestive  appa- 
ratus. It  is  probable,  however,  that,  in  cases  like  the  above,  the  cause, 
if  ascertained,  would  be  found  in  the  ingesta ;  perhaps  drinks  too  hot, 
perhaps  elements  of  colostrum,  or  pathological  elements  in  the  milk, 
which  might  produce  gastritis  in  young  infants  in  whom  the  mucous 
membrane  is  delicate  and  sensitive. 

Gastritis  is  not  uncommon  in  infmcy  in  connection  with  inflamma- 
tion of  the  intestines.  The  latter  inflammation  is  sometimes  apparently 
subordinate  to  the  former,  and,  if  such  patients  die,  the  fatal  result  is 
due  mainly  to  the  gastric  disease.  The  reverse  is,  however,  the  rule. 
The  gastritis  is  ordinarily  subordinate  to  the  intestinal  catarrh. 

Cause. — Gastritis,  as  I  have  observed  it  in  infants,  has  been  in  most 
cases  due  in  great  part  to  the  continued  use  of  improper  food,  of  food 
not  suitiible  to  the  age  of  the  child,  and  which  was,  therefore,  with  dif- 
ficulty digested.  Milk,  acid  or  otherwise  unwholesome,  farinaceous 
substances,  stale  or  of  an  inferior  quality,  and  not  properly  prepared, 
drinks  too  hot  or  too  cold,  may  be  specified  among  the  causes.  Tiiere- 
forc,  this  disease  is  most  common  in  bottle-fed  infants,  and  is  compara- 
tively rare  in  those  who  receive  abundant  and  Avholesome  breast-milk. 
Anti-hygienic  agencies,  apart  from  the  diet,  no  doubt  exert  some  influ- 
ence in  the  production  of  gastritis,  as  they  do  of  stomatitis.  Unclean- 
liness,  and  residence  in  damp  and  dark  apartments,  or  in  an  atmosphere 
loaded  with  noxious  gases,  produce  a  condition  of  system  which  strongly 
predisposes  to  these  inllammations,  if,  indeed,  they  may  not  be  enumer- 
ated among  the  direct  causes. 

Rilliet  and  Barthez  have  called  attention  to  the  fiict  that  certain 
medicinal  substances  given  to  children  occasionally  cause  gastritis. 
They  have  observed  this  eff'ect  from  -the  use  of  tartar  emetic,  kermes 
mineral,  and  croton  oil.  Gastritis  occurring  in  this  way  may  or  may 
not  be  associated  with  inflammation  in  contiguous  portions  of  the  diges- 
tive tube.  Elsewhere  I  have  related  a  case  in  which  gastro-enteritis 
occurred  in  a  child  nine  years  old,  after  having  taken  a  considerable 
quantity  of  kerosene  oil  f^r  spasmodic  croup;  and  Dr.  Northrup,  curator 
of  the  N.  Y.  Foundling  Asylum,  has  seen  the  lesions  of  gastritis  in 
infants  that  took  carbonate  of  ammonium  in  the  last  days  of  life. 

Inflamni;ition  of  the  stomach  is  thought  by  some  to  accompanv 
measles  and  scarlet  fever  during  the  eruptive  period,  but  this  opinion  is 
probably  incorrect.  If  it  occur,  it  corresponds  with  the  stomatitis  and 
dermatitis  of  tliose  diseases,  and  disappears  as  they  subside.  It  is  mild, 
and  accompanied  by  few  symptoms.  I  have,  as  stated  in  the  remarks 
c»n  scarlet  fever,  examirietl  in  certain  instances  the  stomachs  of  tliose 
who  have  dieil  during  the  eruptive  period  of  these  diseases,  and  found 
them  free  from  any  appreciable  inflammatory  lesion. 

AoE. — From  the  records  of  about  seventy  cases  of  inflammatory  dis- 
ease of  ilie  digestive  mucous  membrane  which  I  liave  preserveil,  it 
appc'ars  that  gastritis  is  rare  over  the  age  of  six  months.  On  the  other 
haml.  it  is  not  uncommon  in  infants  under  the  aire  of  three  montlis  who 
are  deprived  of  breast-milk.  I  have  met  it  chiefly  in  foundlings  fed 
with  the  bottle,  and  liaving  at  the  same  time  cntero-colitis  and  often 
also  stomatitis  and  oesophagitis.     In  these  cases  there  is  sometimes  con- 

45 


706  GASTRITIS. 

tinuous  or  almost  continuous  injection  and  tliickening  of  the  mucous 
membrane,  from  the  lips  to  near  the  pyloric  orifice  of  the  stomach,  and 
even  beyond  this  orifice  in  the  intestines.  The  following  is  an  example 
of  gastritis  as  it  frequently  occurs  in  foundling  institutions : 

Case. — R.  W.,  female,  two  weeks  old,  was  admitted  into  the  Ncav  York 
Infant  Asylum,  August  24,  18G5,  amemic  and  somewhat  emaciated.  She 
was  in  part  wet-nursed,  and  in  jjart  bottle-fed.  The  emaciation  increased, 
and  nearly  the  entire  buccal  cavity  became  covered  with  the  confervoid 
growth  of  thrush.  On  Se})tember  4th,  diarrhwa  commenced.  Borax  Avas 
used  for  the  mouth,  and  alkalies  and  astringents  to  check  the  diarrhtea, 
but  without  material  improvement. 

The  following  was  the  record  for  September  7th :  "  Cries  almost  con- 
stantly, with  feeble  or  whining  voice ;  still  has  thrush  ;  nurses  and  does 
not  vomit ;  stools  five  or  six  daily,  and  green  ;  pulse  loG,  feeble."  Death 
occurred  September  8th. 

Autopsjj  September  9th. — ^fouth  and  fauces  not  examined  ;  mucous  mem- 
brane of  oesophagus  vascular  in  its  whole  extent,  with  slight  thickening, 
hut  without  ulceration  ;  mucous  membrane  of  stomach  injected  like  that 
of  the  oesophagus,  and  somewhat  thickened,  except  in  its  pyloric  extrem- 
ity, where  the  appearance  was  natural,  or  nearly  so  ;  the  color  in  the  cen- 
tral part  of  the  inihimed  gastric  membrane  was  deep  red ;  no  thrush  was 
noticed,  except  on  the  buccal  surface  during  life  ;  along  the  great  curvature 
of  the  stomach  were  white  flakes,  resembling  those  of  thrush,  but  Avhich 
were  found  by  the  microscope  to  consist  mainly  of  oil-globules  and  epithe- 
lial cells,  without  the  cryptogamic  formation  ;  mucous  mendirane  of  small 
intestines  healthy  in  their  whole  extent,  except  slightly  increased  vascu- 
larity in  a  few  places  in  the  ileum  ;  mucous  membrane  of  colon  much 
injected  throughout,  except  near  the  ileo-Ccecal  valve,  where  the  vascu- 
larity was  slight ;  in  the  transverse  and  descending  colon  the  redness  was 
pretty  uniform;  and  the  membrane  was  thickened,  but  not  ulcerated; 
solitary  glands  and  Peyer's  patches  moderately  elevated. 

The  observations  of  Valleix  show  how  frequently  gastritis  is  associated 
•with  severe  attacks  of  thrush.  In  twenty-three  of  his  cases  of  the  latter 
disease,  in  which  the  condition  of  the  stomach  was  noted  after  death, 
this  organ  ])resented  inflammatory  lesions  in  seventeen,  and  in  three 
others  appearances  which  may  or  may  not  have  been  due  to  inflammation. 

Symptoms. — A  difficulty  exists  in  isolating  and  defining  the  symp- 
toms of  gastritis,  from  the  fact  that  it  commonly  coexists  Avith  other  in- 
flammations of  the  digestive  tube.  Though  Ave  may  never  be  able  to 
diagnosticate  this  catarrh  as  certainly  as  Ave  can  croup  or  pneumonitis, 
still,  there  are  symptoms  Avhich  arise  directly  from  the  gastritis,  and 
A\4th  caie  Ave  may  be  able  to  distinguish  them  from  those  symptoms 
which  are  due  to  other  pathological  states. 

If  gastritis  be  acute,  pain  is  present.  In  the  above  case  from  Billard, 
as  Avell  as  in  a  case  observed  by  myself  and  related  under  the  head  of 
gelatinous  softening,  there  Avere  frequent  cries,  and  the  countenance  in- 
dicated much  suffering,  until  the  stage  of  collapse.  If  there  be  less 
intensity  of  inflammation,  aud  the  disease  be  more  protracted,  as  is  ordi- 
narily the  case,  the  pain  is  not  so  severe,  and  it  may  be  so  slight  as  not 
to  attract  attention.  Sometimes  there  is  tenderness,  so  that  pressure 
upon  the  epigastric  region  is  badly  tolerated.     Vomiting  is  regarded  as 


DIAGNOSIS PROGNOSIS,  707 

one  of  the  most  constant  symptoms.  The  infant  aftei*  nursing  seems  in 
distress  till  the  milk  is  returned,  but  it  nurses  with  avidity  in  conse- 
quence of  the  thirst,  if  it  be  not  too  exhausted  or  feeble.  The  dejections 
may  be  quite  regular  throughout  the  disease,  as  in  the  case  from  Billara. 
There  is  ordinarily,  however,  diarrhoea  from  the  presence  of  entero- 
colitis. The  pulse  is  sometimes  accelerated,  and  sometimes  nearly 
natural.  The  emaciation  in  gastritis  is  rapid,  since  not  only  the  milk 
is  in  great  measure  vomited,  but  the  digestive  function,  so  far  as  the 
stomach  is  concerned,  is  seriously  impaired.  The  features  become 
wrinkled  and  senile,  the  eyes  hollow,  the  limbs  attenuated,  and  the 
cranial  bones  uneven.     Death  occurs  from  exliaustion. 

Anatomical  Characters. — Simple  gastritis  may  affect  the  entire 
mucous  surface  of  the  stomach,  or  be  limited  to  a  certain  part.  The  part 
which  is  most  likely  to  escape  is  that  toward  the  pyloric  orifice.  This 
portion  of  the  oi-gan  is  sometimes  found  in  nearly  or  quite  the  normal 
state,  while  the  cardiac  hall  ^.  u»vo-thirds  is  inflamed.  The  vascularity 
of  the  diseased  surface  is  not  uniform.  In  one  place  there  is  simple 
arborescence ;  in  another  intense  continuous  redness,  and  between  these 
two  extremes  are  different  grades  of  vascularity.  The  mucous  mem- 
brane is  somewhat  thickened,  softened,  and  the  secretion  of  mucus  in- 
creased. Extravasation  of  blood  is  not  infrequent  under  the  mucous 
membrane,  usually  in  points,  and  mucus  maybe  mixed  with  more  or 
less  blood.  Small  shreds  or  portions  of  coagulated  milk  are  often  found 
with  the  mucus  attaclied  to  the  gastric  surface.'  I  have  observed,  though 
rarely,  small  superficial  ulcers  at  the  point  where  the  inflammation  had 
been  most  intense. 

Diagnosis. — In  protracted  cases,  when  entero-colitis  is  present,  it  is 
difficult  to  make  a  positive  diagnosis.  Our  opinion  must  then  be  little 
more  tlian  a  plausible  conjecture.  In  the  acute  attacks  we  can  diagnos- 
ticate the  gastritis  with  more  certainty.  If  a  .young  infant  affected 
with  sprue  be  seized  with  pain,  and  it  vomit  often ;  if  emaciation  be 
rapid,  and  there  be  no  diarrhoea,  or  diarrhoea  not  sufficient  to  account 
for  the  prostration ;  if  the  buccal  mucous  membrane,  dotted  with  the 
points  of  thrush,  present  a  dry  appearance  and  the  deep  red  color  of 
severe  stomatitis,  there  can  be  little  doubt  of  the  presence  of  gastritis. 
The  diagnosis  is  rendere<l  more  certain  by  signs  of  tenderness  when 
pressure  is  made  upon  the  epigastric  region. 

PuoGXOSis, — Like  other  inflammations,  gastritis  is  probably  sometimes 
so  mild  that  it  does  not  materially  increase  the  suffering  or  danger  of  the 
child.  This  mild  form  of  the  disease  un<ler  favorable  circumstances  soon 
subsides.  In  other  cases,  by  the  continuance  or  increase  of  the  cause, 
the  inflammatory  process  becomes  more  severe  and  extensive,  resulting 
even  in  disintegration  of  the  mucous  meml»rane.  Those  cases  arc  espe- 
cially severe  and  likely  to  end  fatally,  which  are  protracted  and  accom- 
panied by  severe  thrush,  with  a  desiccated  appearance  of  the  buccal 
surface,  or  with  entero-colitis.  Pain,  vomiting,  and  rapid  emaciation 
in  such  children  indicate  the  speedy  approach  of  death.  Improvement 
in  the  stomatitis  or  entero-colitis  is  a  favorable  indication,  but  these 
inflammations  may  improve  without  corresponding  improvement  in  the 
gastritis. 


708  DIPHTHERITIC    GASTRITIS. 

Treatment. — All  food  or  drinks,  except  those  of  a  bland  and  unirri- 
tating  nature,  should  be  forbidden.  If  practicaltle,  the  young  infant 
should  take  no  nutriment  except  the  mother's  milk  or  that  of  a  wet- 
nurse.  Since  there  is  an  excess  of  acid  in  inllannnation  of  the  mucous 
coat  of  the  digestive  tube,  lime-water  may  be  advantageously  given  in 
condjination  with  breast-milk.  Opium  is  required  to  relieve  the  pain 
and  (piiet  the  action  of  the  stomach.  The  camphorated  tincture  of 
opiuiu,  in  doses  of  four  or  five  drops  to  a  child  a  month  old,  or  the 
syrup  of  poppy,  tincture  of  opium,  orli([Uor  opii  compositus,  in  propor- 
tionate doses,  may  be  administered.  If  there  be  thirst,  a  little  gum- 
Avatcr  should  be  given  fro(iuently.  If  there  be  much  emaciation  and  the 
vital  powers  are  failing,  it  will  bo  necessary  to  resort  to  the  use  of  stim- 
ulants. Stimulating  enemata  are  preferable  to  stimulants  given  by  the 
mouth.  Much  benefit  may  be  anticipated  from  local  measures.  Irri- 
tation should  be  produced  upon  the  epigastrium  by  mustard  or  other 
means,  followed  by  fomentations.  It  is  rarely,  perhaps  never,  proper 
to  use  leeches,  if  the  patient  be  a  young  infant.  Death  occurs  from 
exhaustion,  and  it  is,  therefore,  important  that  the  vital  powers  should 
not  be  reduced.  If  the  child  be  w^eaned,  the  diet  at  first  should  be 
restricted  to  arrowroot,  rice-water,  barley-water,  or  similar  bland  sub- 
stances. In  advanced  stages  of  gastritis,  animal  broths  and  jellies  may 
be  required. 


Follicular  Gastritis — Diphtheritic  Gastritis. 

The  pathological  character  o^  follicular  gastritis  is  similar  to  tliat  of 
follicular  stomatitis.  It  is  an  inflammation  aifecting  the  gastric  follicles 
and  ending  in  their  ulceration.  It  is  not  a  frequent  disease ;  it  occurs 
in  young  infants.  Billard  observed  fifteen  cases.  The  symptoms  in 
these  patients  were  similar  to  those  in  simple  gastritis  of  a  severe  form. 
The  emaciation  and  prostration  were  rapid,  and  death  occurred  early. 
We  can  only  diagnosticate  the  gastritis  without  determining  its  follicular 
character.  How  many  recover  it  is  impossible  to  ascertain,  but  the 
disease  is  likely  to  be  fiital  on  account  of  the  intensity  of  the  inflamma- 
tion, not  ordy  of  the  follicles  but  of  the  intervening  mucous  membrane. 
The  treatment  is  that  of  gastritis. 

Diphtheritic  gastritis  is  infrequent.  It  occasionally  occurs  during 
epidemics  of  diphtheria.  Allusion  is  elsewhere  made  to  a  case  treated 
in  the  Nursery  and  Child's  Hospital  of  this  city,  in  December,  1859. 
The  patient,  eighteen  months  old,  previously  had  had  protracted  entero- 
colitis, and  died  exhausted  after  a  brief  attack  of  diphtheria.  There 
were  lesions  referable  to  the  cntero-colitis,  and  the  body  was  much 
emaciated.  Tiie  diphtheritic  exudation  was  fi)und  covering  the  fauces, 
epiglottis,  glottis  to  the  rima  glottidis,  the  entire  esophagus,  and 
almost  the  entire  stomach.  The  mucous  surfice  underneath  Avas  in- 
jected; that  of  the  oesophagus  and  stomach  especially  Avas  very  vascu- 
lar, softened,  and  thickened,  and  the  submucous  connective  tissue  was 
infiltrated. 

The  pseudo-membrane,  taken  from  the  epiglottis  and  examined  under 


SOFTENING.  709 

the  microscope,  presented  an  amorphous  appearance;  no  cells  were 
noticed  in  it,  and  fibrillation  was  not  distinct ;  that  from  the  stomach 
was  found  to  consist  almost  entirely  of  cells,  the  plastic  corpuscles  of 
some  writers,  the  pyoid  of  others.  The  digestiv-e  process,  so  far  as  the 
stomach  was  concerned,  had  evidently  been  almost  if  not  entirely  sus- 
pended, and  hence  in  part  the  sudden  prostration.  Diphtheritic  gas- 
tritis probably  does  not  occur  without  general  infection  of  the  system 
with  the  diphtheritic  virus.  The  proper  treatment  is  the  use  of  lime- 
water  or  one  of  the  solvents  of  pseudo-membranes  which  do  not  irritate 
the  mucous  membrane,  Avhile  the  constitutional  treatment  proper  for 
diphtheria  is  employed. 


Post-mortem  Digestion — Softening. 

It  is  now  many  years  since  the  attention  of  the  profession  was 
directe<l  to  disorganization  of  the  coats  of  the  stomach,  Avhich  is  some- 
times observed  at  post-mortem  examinations.  John  Hunter  first  ascer- 
tainetl  that  the  gastric  juice  begins  to  have  a  solvent  effect  on  the  tis- 
sues of  the  stomach  soon  after  death.  Though  Hunter  erred,  when  he 
stated  that  the  coats  of  the  stomach  are  more  or  less  digested  in  all 
or  nearly  all  cases,  it  is  certain  that  post-mortem  digestion  does  take 
place  in  many  cadavers,  so  that  in  a  few  hours  after  death  the  gastric 
mucous  membrane  is  destroyed  to  a  greater  or'less  extent,  and  occasion- 
ally the  stomach  is  perforated  or  is  even  severed  from  its  connection 
with  the  oesophagus.  I  have  seen  several  examples  of  this  post-mortem 
digestion  in  inflmts. 

Some  of  the  ca^es  of  supposed  pathological  softening  of  the  stomach 
reported  by  the  older  observers,  seem  to  have  been  such  as  I  have 
described,  namely,  cadaveric.  Yet  there  are  two  other  kinds  of  soften- 
ing occurring  in  children,  which  are  strictly  pathological,  the  one 
designated  white,  the  other,  by  Cruveilhier,  gelatinous. 

WiHTE  softening  of  the  gastro-intestinal  raucous  membrane  results 
from  dL^ficient  alimentation.  It  has  been  observed  only  in  anaemic  and 
ill-n()urishe(l  children.  The  mucous  membrane  in  such  patients  loses  its 
firmness,  and  is  easily  separated  from  the  subjacent  tissue.  This  soft- 
ening has  no  connection  with  any  intlammatory  process.  It  is  the 
result  of  the  low  vitality  of  the  patient.  I  believe  that,  in  a  large  pro- 
portion of  infants  whose  systems  have  been  reduced  and  blood  impover- 
ished for  a  considerable  time,  the  gastro-intestinal  mucous  meml)raiie 
will  be  foiin<l.afLer  death  less  firm  and  resisting  than  in  those  who  have 
been  hal)itually  roljust. 

A  vague  opinion  exists  in  the  minds  of  most  physicians  as  to  the 
nature  and  even  appearance  of  the  so-called  </elatmous  softening  of  the 
stomach,  and  the  following  observations  will  be  cited  in  order  to  give  a 
clearer  idea  of  it. 

IJilhinl  has  recorded  two  cases  with  his  usual  minuteness,  and  adds: 
"What  inference  shall  be  drawn  from  the  preceding  facts  and  considera- 
tions? None  other  than  that  the  gelatinous  softening  of  the  stomach 
consists  in  a  disorganization  of  the  mucous  membrane  of  this  viscus, 


710  SOFTENING. 

caused  by  an  acute  or  chronic  phlegmasia ;  that  this  disorganization  is 
characterized  by  an  accumulation  of  serum  in  the  Avails  of  this  organ; 
the  intumescence  and  geUitinous  consistence  of  the  nmcous  membrane 
in  a  part  usually  circumscribed,  situated  more  frequently  in  the  greater 
curvature,  and  about  which  the  membrane  exhibits  more  or  less  evident 
traces  of  an  acute  or  chronic  phlegmasia.  .  .  .  The  softening  now 
under  consideration  must  not  be  confounded  with  another  kind  of  soften- 
ing "  (white)  "■which  does  not  usually  succeed  an  acute  phlegmasia." 

Billard  believes  that,  while  gelatinous  softening  re^'ults  from  inHam 
mation  of  the  mucous  membrane,  its   proximate  cause  is  an   afflux  of 
serum  to  the  part  in  which  the  disorganization  occurs.     In  one  of  the 
two  cases  which  he  reports,  he  thinks  that  the  inflammation  Avas  acute, 
but  in  the  other  chronic,  and,  therefore,  presenting  less  vascularity. 

West,  in  speaking  of  gelatinous  softening,  says:  "  Softening  of  the 
stomach  varies  in  decree  from  a  slio-ht  diminution  in  the  consistence  of 
the  mucous  membrane,  to  a  state  of  complete  diffluence  of  all  the  tissues 
of  the  organ.  .  .  .  When  the  change  is  not  far  advanced,  the  ex- 
tei-ior  of  tlie  stomach  presents  a  perfectly  natural  appearance,  but  on 
laying  it  open  a  colorless  or  slightly  broAvnish  tenacious  mucus,  like  the 
mucilage  of  quince-seed,  is  found  closely  adhering  to  its  interior,  over  a 
more  or  less  considerable  space  at  the  great  end  of  this  organ." 

Cruveilheir  says:  "This  softening  often  proceeds  from  the  interior 
toAvard  the  exterior.  There  is  at  the  beginning  simple  separation  of 
the  fibres  by  a  gelatinous  mucus,  and  in  consequence  the  parietes  are 
thickened  and  semi-tr:insparent.  ...  If  the  transformation  be 
complete,  the  disorganized  portions  are  removed  layer  after  layer,  those 
Avhich  remain  becoming  gradually  thinner.  The  peritoneum  alone  re- 
sists for  some  time,  but  at  length  it  is  attacked,  Avorn,  and  gives  Avay, 
and  perforation  of  tlie  stomach  results.  The  parts  thus  transformed  are 
colorless,  transparent,  apparently  inorganic,  completely  deprived  of  ves- 
sels, and  exhaling  an  odor  resemblinoj  that  of  milk." 

Bouchut  remarks:  "  Softening  of  the  mucous  membrane  of  the  stom- 
ach in  children  at  the  breast  is  not  a  special  disease  Avhich  it  is  necessary 
to  describe  by  itself.  This  alteration  is  ahvays  connected  with  other 
diseases,  and  especially  Avith  disease  of  the  large  intestine,  the  knoAvl- 
edge  of  Avhich  fict  has  been  too  long  neglected.  It  is  the  consecpience 
of  the  acidity  of  the  liquids  contained  in  the  digestive  tube  of  young 
children,  liquids  Avhich  are  very  acid  in  the  disease  Ave  have  above  re- 
ferred to." 

Dr.  CarsAvell  states  that  there  is  a  pathological  softening  of  the 
mucous  membrane  of  the  stomach,  and  that  Avhen  it  occurs  the  symp- 
toms may  be  those  of  gastritis  or  enteritis. 

Rokitansk}^  says  of  this  forui  of  softening:  "If  Ave  consider,  in  addi- 
tion to  the  above  remarks,  the  uniform  localization  of  the  disease,  that 
in  none  of  its  stages  it  presents,  either  at  the  point  of  the  softening  or 
in  its  vicinity,  hypersemic  injection  or  reddening,  and  that  we  are  still 
less  able  to  demonstrate  upon  the  inner  surface  of  the  stomach  or  in  the 
tissue  of  its  coats  tlio  ])roducts  of  iiitlauimation,  Ave  are  constrained  to 
infer  the  non-innammatory  nature  of  the  affection." 

Without  extendini;  these  extracts,  it  is  seen  that  eminent  authorities 


SOFTENING.  711 

not  onlv  disagree  in  reference  to  the  cause  of  gelatinous  softening  of  the 
stomach,  but  that  tliey  also  differ  in  their  description  of  its  appearance. 
This  diversity  of  opinion  is  most  likely  attributable  to  the  fact  that  the 
two  kinds  of  softening  have  been  confounded.  Rokitansky  and  Bouchut 
probably  refer  to  cases  of  white  softening,  which  occurs  in  atonic  states 
of  the  tissues  in  feeble  infants,  and,  therefore,  have  concluded  that 
softening  of  the  stomach  is  not  inflammatory.  I  believe,  from  my  ob- 
servations, that  the  opinion  of  Billard  is  correct,  and  that  true  gelati- 
nous softening  is  the  result  of  gastric  inflammation,  sometimes  chronic, 
sometimes  acute.  But  I  have  seen  appearances  which  led  me  to  think 
that  the  immediate  causes  of  the  softening  continue  to  operate  after 
death,  so  that  its  amount  is  less  at  the  time  of  death  than  a  few  hours 
subset  juently. 

The  following  case,  which  was  watched  by  myself  with  great  interest, 
from  beginning  to  end,  is  an  example  of  inflammatory  softening: 

Case. — G.  S.,  male,  robust,  was  born  July  10,  1865.  The  mother  not 
being  able  to  suckle  the  infant,  and  the  danger  of  artificial  feeding  in  the 
warm  months  being  well  understood,  a  wet-nurse  was  procured.  About 
the  14th  of  July,  this  wet-nurse  having  insufficient  milk,  another  was  pro- 
cured temporarily,  who  suckled  the  infant  till  July  20th,  when  a  third 
wet-nurse  wjis  engaged,  whose  child,  healthy  and  thriving,  was  six  weeks 
old.  Previously  to  this  time  the  infant  appeared  Avell.  It  had  uniformly 
nursed  vigorously  and  seemed  satisfied. 

On  the  'I'ld  of  July,  thrush,  apparently  nlild,  was  oljserved  in  the 
mouth,  and  a  powder,  supposed  to  be  borax,  and  labelled  such,  was  ob- 
tained at  a  druir-store,  to  be  used  as  a  wash  for  the  mouth.  This  powder 
was  afterward  ascertained  to  be  alum.  Five  grains  were  dissolved  in 
as  many  tea.s])oonf'uls  of  water,  and  the  mouth  of  the  child  was  swabbed 
occasionally  with  it.  A  ])iece  of  linen,  folded  so  as  to  resemble  the  tip 
of  a  nursing-bottle,  was  occasionally  dipped  into  the  solution,  and  the  in- 
fant was  allowed  to  suck  it.  The  use  of  the  alum  was  commenced  about 
6  p.  M.  In  the  first  part  of  the  evening  the  infant  slept  considerably,  and 
of  course  did  not  nurse  often,  l)ut  about  8  p.  M.  it  began  to  be  very  fret- 
ful, and  it  then  nursed  more  frequently.  It  vomited  once  between  8  and 
10  o'clock  p.  M.  In  order  to  quiet  the  infant,  the  tip  soaked  in  the  solu- 
tion was  often  applied  to  the  mouth,  but  there  was  scarcely  any  intermis- 
sion in  its  crying.  Throutih  the  niizht  it  vomited  atrain  once  or  twice, 
and  about  the  middle  of  the  night  had  one  free  liquid  stool,  which  was 
passed  with  nuich  tenesmus.  The  countenance  of  the  infant  was  indica- 
tive of  suHliring,  and  its  thii^hs  were  repeatedly  flexed  over  the  abdomen, 
as  if  that  were  the  seat  of  its  distress.  Parej^oric  in  two-drop  doses  was 
several  times  given  through  the  night,  and  flannel  soaked  with  hot  whiskey 
was  applied  to  the  abdomen. 

July  2  >d.  In  ignorance  of  the  cause  of  the  child's  sickness,  another 
wet-nurse  was  obtained  early  in  the  morning,  and  one-sixth  of  a  drop  of 
li(|.  opii  com])os.  was  given  every  hour,  with  the  effect  of  induciu'i  a  little 
sleep.  The  tongue  was  very  red,  desiccated,  and  studded  with  more 
numerous  j)oints  of  thrush  than  on  the  ))revious  day.  It  now  refused  to 
nurse,  apparently  from  .sorfnc's,s  of  the  ton;;ue.  At  each  attempt  of  the 
nurse  to  induce  it  to  take  th(^  nipple,  it  rubbed  the  mouth  across  the 
breast,  crvin.''  fithcr  from  pain  or  disappoiutnient.  The  alum  was  not 
used  in  the  latter  parL  of  the  niirht  of  the  'J2d,  but  late  in  the  morning  of 


712  SOFTENING, 

the  2.^d  it  was  resumed,  the  mistake  of  the  druggist  not  being  discovered 
till  midday,  when  it  was  estimated  that  about  five  grains  had  been  used. 
Occasionally  a  little  of  the  solution  was  placed  in  the  mouth  with  a  spoon 
S!>  as  to  be  swallowed,  in  the  belief  that  the  thrush  affected  the  oesopha- 
gus. The  infant  continued  to  sutler  much  during  the  day,  sleeping  at 
times  a  few  minutes.  Its  strength  was  evidently  failing;  respiration  reg- 
ular ;  pulse  about  140  ;  its  alvine  discharges  yellow,  of  naiural  consistence 
and  fre(|uency. 

Evening,  2od.  Surface  hot;  it  is  very  restless;  pulse  150  to  160; 
tongue  dry,  intensely  red,  aud  dotted  with  points  of  thrush.  Is  treated 
with  opiates,  a  little  lime-water,  and  fomentations. 

24th.  In  the  first  part  of  the  day  nursed  pretty  well  ;  in  the  latter  part, 
could  be  induced  to  draw  the  breast  only  once  or  twice.  The  symptoms 
to-day  were  the  same  as  yesterday,  with  the  exception  of  greater  emacia- 
tion and  prostration  ;  cranial  bones  uneven,  and  features  pinched. 

2")th.  Pulse  140  to  148;  strength  rapidly  failing,  but  it  cries  at  times 
loudly.  The  milk  of  the  nurse,  placed  in  the  mouth  with  a  spoon,  is 
often  held  a  considerable  time  before  it  is  swallowed,  and  deglutition 
seems  difticult.  Respiration  in  the  first  part  of  the  day  and  previously, 
natural ;  in  the  latter  part  of  the  day,  accelerated  ;  dejections  natural ;  no 
vomiting;  appeai'ance  of  tongue  more  natural  than  yestei'duy. 

26th.  Died  to-day  in  a  state  of  collapse  at  12^  p.m.  The  hands  were 
cold  several  hours  before  death,  and  the  milk  given  it  was  regurgitated. 

Aufop.ty  ficeutii-hvo  hours  after  death. — Much  emaciation  ;  no  rigor  mor- 
tis ;  cranial  bones  uneven  ;  the  upper  ])art  of  the  pharynx  injected  to  the 
extent  of  about  half  an  inch  ;  from  this  point  to  the  stomach  membrane 
healthy ;  mucous  membrane  covering  the  cardiac  two-thirds  of  the  stomach 
disintegrated,  almost  diffluent,  and  iu  places  detached  from  the  subjacent 
tissues ;  mucous  coat  of  the  pyloric  third  of  the  organ  nearly  healthy ; 
along  the  edge  of  the  softened  portion  the  mucous  mend^ranewas  vascular 
to  the  extent  of  a  few  lines  ;  the  muscular  and  serous  coats  of  the  stomach 
underneath  the  softened  portion  were  easily  torn  ;  the  mucous  membrane 
of  the  small  intestine  presented  in  jilaces  that  degree  of  vascularity  known 
as  arborescence  ;  there  was  no  destruction  or  softening  of  its  mucous  mem- 
brane ;  the  colon  was  healthy;  the  stomach  was  nearly  empty  ;  the  con- 
tents of  the  small  and  large  intestines  wen?  natural  in  color  and  consist- 
ence ;  the  other  viscera  were  healthv  ;  in  the  left  pleural  cavity  was  about 
one  ouuce  of  transparent  serum,  and  a  less  quantity  in  the  right  cavity. 

It  cannot  be  doubted  that  the  softening  in  the  above  case  was  patho- 
logical. The  weather  at  the  time  was  warm^  but  the  infant,  was  placed 
on  ice,  and  a  pan  containing  ice  was  kept  upon  the  abdomen.  This 
infant  died  evidently  of  gastritis,  the  accompanying  inflammation  being 
subordinate,  and  in  fact  insignificant.  At  first  it  was  a  question  with 
me  Avhether  the  alum  might  not  liave  caused  the  gastritis,  so  tliat  the 
case  should  be  properly  placed  in  the  category  of  deaths  from  swallow- 
ing corrosive  substances.  In  order  to  determine  this  point,  I  adminis- 
tered alinn  daily  to  two  kittens,  commencing  when  they  were  seven  days 
old.  The  quantity  given  to  each  was  ten  grains  daily  in  two  doses  for 
three  consecutive  days,  and  on  tlie  two  following  days  five  grains.  The 
only  uniform  residt  noticed  was  an  increased  flow  of  saliva,  which  waslied 
some  of  the  alum  from  their  mouths,  and  occasionally  slight  vomiting. 


XON- INFLAMMATORY    DIARRHCEA.  713 

There  wa=!  not  even  any  apparent  inflammation  of  the  buccal  membrane 
from  the  ahim. 

Post-mortem  appearances  as  in  tlie  above  case,  and  simihir  ones 
recorded  by  Valleix  and  others,  in  which  gelatinous  softening  coexisted 
with  evident  lesions  of  gastritis,  render  it  highly  probable,  if  indeed 
they  do  not  demonstrate,  that  the  softening  is  a  result  of  the  inflamma- 
tion at  the  point  -where  it  occurs. 

In  Yalleix's  twenty-four  cases  of  what  he  terms  fatal  muguet,  soften- 
ing of  the  mucous  membrane  of  the  stomach  was  one  of  the  most  com- 
mon lesions,  and  at  the  same  time,  which  is  the  point  of  interest,  there 
were  signs  which  showed  conclusively  the  presence  of  gastric  inflamma- 
tion. The  common  coexistence  of  the  lesions  of  gastric  inflammation, 
such  as  redness  and  thickening,  with  gelatinous  softening  of  the  stomach, 
is  certainly  most  reasonably  explained  on  the  supposition  that  the  one 
results  from  the  other. 

I  am  not  prepared  to  accept  nor  reject  the  theory  of  Billard,  that 
the  immediate  cause  of  the  softening  is  the  afflux  of  serum,  nor  that  of 
Bouchut,  that  it  is  an  excess  of  acid. 

It  has  been  said  that  M.  Baron  was  able  to  diagnosticate  gelatinous 
softening.  The  symptoms  are  those  of  the  severe  forms  of  gastritis. 
The  vomiting,  great  pain,  restlessness,  sudden  and  progressive  emacia- 
tion, and,  finally,  collapse  ])receding  the  fatal  result,  without  sufficient 
diarrhoea  to  cause  the  rapid  sinking,  are  the  symptoms  on  wiiich  the 
diagnosis  is  based.     The  treatment  should  be  directed  to  the  I'astritis. 


CHAPTER  YII. 

DIARllIKEA. 

DiARRiiCEA  is  frequent  during  the  whole  period  of  infancy.  French 
writers  describe  sevei^al  varieties,  according  to  the  character  of  the  evacua- 
tions, as  acescent,  mucous,  and  serous.  M.  llostan  evi'n  describes  four- 
teen distinct  kinds.  But  the  tendency  of  medical  science  in  modern 
times  is  to  simplify  the  nomenclature  of  diseases — to  describe  under  a 
single  name  those  affections  which  are  essentially  the  same  though  dif- 
fering somewhat  in  their  features.  Now,  all  the  forms  of  diarrhoea  in 
the  infant  may  be  so  grouped  as  to  re<liice  the  number  to  not  more  than 
three  or  four.  In  this  way  repetition  and  prolixity  arc  avoided,  as  well 
as  an  unnecessary  refinement. 

Non-Inflamtnatory  Diarrhoea. 

The  most  common  form  of  diarrlnca  is  that  cniincinhMl  in  our  licad- 
ing,  which  writers  sometimes  designate  by  the  term  simple  or  spasmodic. 


714  NOX-IXFLAMMATORY    DIARRHCEA. 

But  often  a  diarrhoea  "whicli  is  non  inflammatory  at  first,  becomes  a 
catarrh.  Thus  the  simple  diarrhoea  of  infancy  may  become  an  entero- 
colitis from  the  continued  use  of  improper  diet. 

Causes. — These  are  various.  Conditions  or  agencies  "vvhicli  liave  no 
appreciable  cftect  in  the  adult  often  increase  the  number  of  evacuations 
in  young  children.  Food  "which  imperfectly  digests,  and  some  of  ■which 
perhaps  ferments,  stimulates  the  intestinal  follicles  to  excessive  secre- 
tion, and  increases  the  peristaltic  movements  by  its  irritating  action, 
thus  causing  diarrhoea.  Too  frequent  and  abundant  feeding  is  another 
cause,  especially  in  young  infants,  some  of  Avhom  may  vomit  the  surplus 
food  and  remain  "well,  but  others  do  not.  Food  which  cannot  be  assimi- 
lated becomes  an  irritant  in  consecjuence  of  fermentative  change,  and 
produces  frequent  and  unhealthy  evacuations.  The  late  Dr.  James 
Jackson,  of  Boston,  directed  attention  to  this  cause  of  diarrhoea  in  his 
Letters  to  a  Younr/  Physician. 

The  mother's  milk  or  the  milk  of  the  "wet-nurse  may  disagree,  either 
from  some  temporary  derangement  of  her  system,  or  continued  ill- 
health,  or  from  causes  Avhich  are  not  understood.  Kon-intlanmiatory 
diarrhoea  in  the  nursling  is  the  immediate  result,  "with  perhaps  subse- 
quent inflammation.  The  milk  in  those  cases  frequently  contains  the 
elements  of  colostrum. 

Fright  or  strong  mental  impressions  "will  also  in  some  children  increase 
the  number  of  evacuations.  This  cause  being  transient,  the  diarrhoea 
soon  subsides. 

Another  cause  is  exposure  to  cold.  Children  "who  are  insufficiently 
clothed  in  the  winter  season,  who  are  taken  from  a  heated  room  into  a 
cool  one  Avithout  sufficient  protection,  or  who  lie  uncovered  at  night, 
are  very  subject  to  diarrhoeal  attacks  from  the  impression  of  cold  on  the 
system. 

The  cause  of  non-inflammatory  diarrlnxa  may  exist  in  the  child  itself. 
In  some  children  the  evolution  of  the  teeth  is  attended  by  a  relaxed 
state  of  the  bowels,  Avhich  ceases  when  the  gum  is  pierced.  Worms  in 
the  intestines  may  also  operate  as  a  cause.  Diarrhoea  is  occasionally 
salutary  within  certain  limits,  and  of  course  it  is  not  strictly  correct  to 
call  it  a  disease  when  it  is  a  means  of  relief.  If  occurring  from  exces- 
sive or  irritating  ingesta,  it  is  obviously  conservative. 

Symptoms. — Non-inflammatory  diarrhoea  may  come  on  suddenly  ;  at 
other  times  there  are  precursory  symptoms  continuing  for  some  days. 
"Whether  or  not  there  be  antecedent  symptoms  depends  chiefly  on  the 
cause.  If  this  be  exposure  to  cold,  or  the  use  of  improper  aliment,  it 
commonly  occurs  immediately. 

Among  the  prodromic  symptoms  sometimes  present  are  restlessness, 
disturbed  sleep,  transient  abdominal  pains,  nausea,  or  vomiting,  and 
other  symptoms  of  indigestion.  The  stools  in  simple  diarrhoea  differ 
much  in  color  and  consistence  in  different  cases,  and  perhaj)s  at  differ- 
ent periods  in  the  same  case.  In  infants  they  are  apt  to  be  green. 
This  color,  which  is  a  source  of  anxiety  to  the  inexperienced,  and 
especially  to  the  parents,  is  often  produced  by  trivial  causes.  Slight 
indigestion  will  produce  it,  and  so  Avill  excess  of  food,  even  when  l)land 
and  unirritating.     The  stools  in  infantile  diarrhoea  often  contain  jiarti- 


ANATOMICAL  CHARACTERS.  715 

cles  of  coagulated  casein,  but  in  children  advanced  beyond  the  period 
of  first  dentition  they  do  not  diifer  materially  in  appearance  from  the 
evacuations  of  the  adult.  They  are  usually  passed  easily,  but  if  they 
be  acid  or  in  any  way  irritating,  there  may  be  more  or  less  tenesmus, 
especially  in  infants.  Sometimes  before  the  evacuations,  there  is  a 
sensation  of  fulness  in  the  abdomen.  In  that  form  of  diarrhoea  which 
has  been  designated  acescent,  not  only  are  the  stools  acid,  but  matters 
vomited  have  an  acid  odor,  and  give  an  acid  reaction. 

During  the  quiet  hours  of  sleep,  when  no  food  and  drinks  are  taken, 
the  diarrh(33a  diminishes.  If  the  complaint  be  slight,  there  is  little 
thirst ;  but  if  the  stools  be  frequent  and  thin,  especially  if  they  approach 
the  watery  character,  the  patient  is  thirsty.  The  appetite  varies,  the 
tongue  is  moist,  and  covered  with  a  light  fur,  and  there  is  often  more  or 
less  meteorism,  but  no  abdominal  tenderness. 

The  features  in  this  disease  are  pallid.  In  a  few  days,  if  the  evacua- 
tions continue,  there  is  evident  loss  of  weight  and  flesh.  The  rotundity 
of  the  limbs  is  gradually  lost,  and  the  tissues  become  soft  and  flabby. 
But  in  most  cases,  when  the  maladv  has  reached  this  stai^e,  its  oriirinal 
character  is  lost,  and  it  has  become  inflammatory. 

There  is  no  constant  fever  in  true  non-inflamuiatory  diarrhoea.  Some- 
times the  pulse  is  accelerated  in  the  latter  part  of  the  day,  but  usually 
only  for  a  short  time. 

Certain  epiphenomena,  as  Barrier  terms  them,  occur  at  times  in  non- 
inflammatory as  v.ell  as  in  inflammatory  diarrhcea,  as  for  example  a 
sympathetic  cough,  or,  which  is  more  serious,  cerebral  complicati(ms. 
Convulsions  or  stupor,  indicating  the  supervention  of  spurious  hydro- 
cephalus, may  occur  in  either  form  of  diarrhoea.  This  disease  is  de- 
scribed elsewhere. 

AxATOMiCAL  Characters. — It  is  obvious  from  the  nature  of  this 
malady  that  it  is  attended  by  little  or  no  structural  changes  percei)tible 
to  the  anatomist.  In  cases  supposetl  to  be  non-inflammatory,  which 
have  ended  fatally  either  from  the  diarrluea  or  an  intercurrent  disease, 
the  most  marked  lesions  observed  have  been  more  or  less  tumefaction  of 
the  intestinal  glands,  with  perhaps  diminished  firmness  and  resistance 
of  the  mucous  membrane.  Cases  like  the  following,  which  have  usually 
been  regarded  as  non-inflammatory,  are  not  infrequent,  but  it  seems  to 
me  probable  that  in  at  least  a  certain  proportion  of  such  cases  the  intes- 
tinal follicular  a])])aratu3  has  passed  beyond  the  ])hysiological  state  of  an 
exaggerated  functional  activity,  and  that  the  disease  should  be  desig- 
nated a  catarrh  or  inflammation.  Inasmuch  as  non-inflannnatory  diar- 
rlioei,  if  protracteil.  is  very  liable  to  become  inflammatory,  it  is  often 
dilficult  to  deteruiine  whether  the  malady  has  undergone  this  change, 
even  with  the  aid  of  a  post-mortem  inspection. 

On  the  Tth  of  July,  l!S(j."),  a  foundling,  one  month  old,  died  at  the 
Infant  Asylum.  It  was  much  emaciated,  with  eyes  sunken  and  features 
pinched,  at  the  time  of  its  death.  It  was  wet-nursed  toward  the  close 
of  its  life,  but  the  nurses  milk  was  insulficient.  It  did  not  vomit;  did 
not  have  any  marked  accelei-ati(»n  of  ])id>e  (1'2J^  per  minute),  audits 
evacuations  were  about  four  daily  ami  tliiii.  Tlic  stomach  and  intestines 
Were  j)ale  throughout.      The  s(ditary  glands,  particulai'ly  those  in  tLie 


716  NOX-INFLAMMATORY    DIARRHCEA. 

colon,  and  the  patches  of  Pcyer,  were  tumefied  so  as  to  be  visible,  and 
somewhat  raised  above  the  surrounding  surface.  But  no  lesions  being 
observed  wliieli  are  characteristic  of  inflammation,  the  disease  was 
reerarded  as  non-intlammatorv. 

Nieraeyer,  with  others,  describes  even  the  mildest  forms  of  diarrhoea 
under  the  term  catarrhal  inflammation,  and  he  appears  to  consider  the 
transient  effects  of  a  purgative  as  an  incipient  catarrh.  But  it  seems  to 
me  preferable,  in  the  present  state  of  pathological  knowledge,  to  regard 
all  those  diarrhoeas  which  immediately  abate  Avith  the  removal  of  the 
cause,  and  which  are  attended  by  no  marked  anatomical  change,  as  non- 
infiaramatory. 

Prognosis. — In  a  large  proportion  of  cases,  non-inflammatory  diar- 
rhoea is  not  dangerous.  With  the  adoption  of  suitable  measures  to 
remove  the  cause,  and  the  use  of  medicines  to  control  the  discharges, 
the  patient  recovers.  The  remark  already  made  may  be  repeated  here, 
that  occasionally  diarrhoBa  is  salutary  within  certain  limits,  as  when 
there  is  a  foreign  substance  in  the  intestines,  either  irritating  mechani- 
cally or  by  its  chemical  properties,  and  wJiich  the  diarrhoea  serves  to 
remove. 

The  danger  arises  from  complications,  as  spurious  hydrocephalus,  or 
from  the  emaciation  and  exhaustion,  or  from  its  eventuatins;  in  inflam- 
mat  ion. 

If  the  rotundity  of  the  figure  and  firmness  of  the  tissues  be  preserved, 
showing  that  alimentation  is  still  sufficient,  and  no  complication  arise, 
the  diarrhoea  is  not  as  a  rule  dangerous.  In  infants  that  over-nurse 
and  do  not  vomit  the  surplus  milk,  the  evacuations  are  sometimes  green 
anl  frequent,  and  yet  fulness  of  figure  is  preserved,  and  the  develop- 
ment of  the  body  proceeds  as  usual.  On  the  other  hand,  diarrhoea 
attended  by  emaciation  or  softness  or  flabbiness  of  the  flesh,  involves 
danger,  and  requires  immediate  treatment. 

Treatment. — It  is  necessary,  in  order  to  treat  diarrhoea  in  infancy 
and  childhood  successfully,  to  ascertain  the  cause,  and,  so  far  as  possible, 
to  remove  it.  It  is  not  till  the  cause  ceases  to  operate,  that  we  can 
expect  a  satisfactory  result  from  medication.  The  disease  may  be  tem- 
porarily relieved  by  medicine,  but  it  usually  returns  at  once  when  treat- 
ment is  omitted,  unless  the  patient  be  removed  from  the  influence  of  the 
agencies  which  produce  it.  These  remarks  are  especially  applicable  to 
the  diarrhoea  of  infants.  With  them  very  generally,  when  afl'ectcd  with 
this  complaint,  there  is  some  fault  as  regards  the  quantity  or  quality  of 
food.  Attention  to  this  matter  will  show  the  need  of  a  change  of  wet- 
nurse,  or,  if  the  infant  be  spoon-fed,  a  change  in  tlie  character  of  its  food 
or  in  the  mode  of  preparation  or  even  in  the  (juantity  given.  Some- 
times by  change  in  the  diet,  and  the  .adoption  of  hygienic  measures,  the 
complaint  ceases,  so  as  to  require  no  medication.  If  medicines  be  needed, 
and  the  symptoms  are  not  urgent,  it  is  occasionally  advantageous  to 
commence  treatment  by  the  use  of  some  of  the  milder  purgatives  in 
small  doses.  In  the  infant^  in  whom  the  dejections  are  so  generally 
acid,  an  alkaline  laxative,  or  a  laxative  conjoined  with  an  alkali,  often 
has  a  good  efl'ect  as  preliminary  treatment.  Half  a  teaspoonful  to  one 
teaspoonful  of  castor  oil,  or  a  proportionate  dose  of  calcined  magnesia, 


TREATMENT.  717 

removes  any  acid  or  irritating  substance  from  the  intestines,  and  is  fol- 
lowed by  a  diminution  in  the  number  of  -stools.  The  improvement, 
however,  without  subsequent  treatment,  is  usually  only  for  a  day  or 
two.  In  this  city  a  purgative  dose  of  castor  oil  is  often  given  as  a 
d.jmestic  remedy  in  infantile  diarrhoea,  the  beneficial  effect  from  it  having 
popularized  its  use  for  this  purpose.  Trousseau  usually  gave  Rochelle 
salts,  but  this  medicine  is  too  severe  and  dangerous  for  the  treatment  of 
infantile  diarrhrea,  especially  in  warm  montlis. 

If  there  have  been  previous  constipation,  and  the  diarrhoea  have  just 
commenced,  a  purgative  is  obviously  indicated.  West  says:  '"Provided 
there  be  neither  much  pain  nor  much  tenesmus,  and  the  evacuations, 
though  watery,  are  fecal,  and  contain  little  mucus  and  no  blood,  very 
small  doses  of  the  sulphate  of  magnesia  and  tincture  of  rhubarb  have 
seemed  to  me  more  useful  than  any  other  remedy  : 

R  . — MiiE^nesioe  sulphatis    .......  ^j. 

Tinet.  rhei  ........  ^j. 

Syr.  zin<iiberis  ........  5  j. 

Aquae  carui         ........  51X. — Misce. 

3J  iLT  dio  for  children  one  yeur  old  ; 

and  I  seldom  fiiil  to  observe  from  it  a  speedy  diminution  in  the  frequency 
of  the  action  of  the  bowels,  and  a  return  of  the  natural  character  of  the 
evacuations." 

In  diarrhoea  of  infants,  due  to  indigestion,  and  attended  by  acidity, 
the  following  prescription  is  sometimes  useful.  By  improving  diges- 
tion and  correcting  acidity,  it  has  a  beneficial  effect  on  the  diarrhoea. 
The  cases  are,  however,  in  my  experience  exceptional  in  Avhich  this  is 
the  proper  remedy  : 

B . — Pulv.  ipecacuanha3    .         .         .         .         .         .         .     £jr.  ss. 

I'lilv.  iliei  ........     trr.  ij. 

S(>d;e  bicarb.       ........     gr.  xij  — Misce. 

Divide  in  chart.  No.  xii.  One  powder  every  four  to  six  ho  irs  to  an  infant  one 
year  old. 

The  effect  of  laxative  medicines,  employed  for  the  purpose  of  correct- 
ing the  functions  of  the  gastro-intestinal  surface,  is  uncertain.  If  no 
improvement  results  from  tiieir  use  within  two  or  three  days,  they 
shouhl  be  omitted.  We  must  rely  on  astringents,  opiates,  and,  in 
infants,  also  on  alkalies.  If  the  symptoms  be  urgent,  if  the  evacuations 
be  fre([ucnt  and  exhausting,  these  agents  should  be  employed  from  the 
first.  Much  harm  is  often  done,  and  precious  time  lost,  by  prescribing 
laxative  mixtures  when  0|)iates  and  astringents  are  re(|uired.  I  have 
know  them  to  aggravate  the  complaint,  when,  by  change  of  mea<^ures, 
imnu'diate  improvement  f()lh)wed.  The  majority  of  cases  of  non-inllam- 
matory  diarrh(ca,  at  the  period  when  the  physician  is  called,  are  best 
treated  by  the  use  of  astringents  and  o])iates  exclusively,  projier  direc- 
tions at  tlie  same  time  being  given  in  reference  to  the  diet  and  hygienic 
management. 

In  the  diarrhoea  of  inflints  the  compound  powder  of  chalk  and  opium 
is  an  excellent  medicine,  containing,  as  it  does,  an  astringent  with  the 
opiate  and  alkali.     It  may  bo  given  in  doses  of  three  grains,  to  a  child 


718  INTESTINAL    CATARRH    OF    INFANCY. 

one  year  old,  every  three  hours.  I  ordinarily  employ  it  -with  double  its 
quantity  of  subnitrate  of  bismuth,  and  know  no  better  remedy  for  ordi- 
nary cases.  The  following  is  a  convenient  formula  for  administering 
substantially  the  same  medicines  in  the  liquid  form : 

R. — Tinct.  opii  deodorat.  .         ......     gtt.  xvj. 

Bisinuth.  subnitrat.    .......      gij 

Syr.  simplie.        .  .  .  .  .  .  .  .      tss. 

Mislur.  c'leipe     ........      5  i»s. — Misce. 

Shake  well  and  give  one  teaspoonful  from  three  to  four  hours. 

In  a  large  majority  of  cases  I  employ  this  prescription,  or  one  similar 
to  it,  from  my  first  visit.  If  the  patient  be  not  relieved  by  the  opiate, 
alkali,  and  bismuth,  and  by  proper  regimen,  in  all  probability  inflamma- 
tion of  the  intestinal  mucous  membrane  is  present.  In  patients  over 
the  age  of  two  or  three  years  simple  diarrhoea  approaches  in  character 
that  of  the  adult,  and  the  treatment  appropriate  for  the  adult  is  proper 
in  these  cases,  allowance  being  made  for  the  difference  in  age.  In  in- 
fants,  in  whom  this  disease,  if  protracted,  is  very  liable  to  eventuate  in 
spurious  hydrocephalus,  alcoholic  stimulants  are  often  required  at  an 
early  period,  on  account  of  the  prostration  and  feeble  power  of  endur- 
ance. 


CHAPTER  Yin. 

INTESTINAL  CATARRH  OF  INFANCY  (ENTERO-COLITIS). 

It  is  customary  with  writers  to  treat  of  inflammation  of  the  small 
and  large  intestines  in  infancy  as  a  single  disease,  for  the  following 
reasons :  First,  the  symptoms  of  colitis  at  this  period  of  life  do  not 
ordinra-ily  differ,  in  any  marked  degree,  fi'om  those  of  enteritis.  The 
tormina,  tenesmus,  and  abdominal  tenderness,  which  characterize  colitis 
in  childhood  and  adult  life,  are  ordinarily  lacking,  or  are  not  appreciable 
by  the  observer;  and  the  muco-sanguineous  evacuations  are  oftener 
absent  than  present.  On  account  of  this  absence  of  symptoms,  Bou- 
chut  says :  "  Dysentery  is  a  very  rare  disease  among  young  children. 
Its  existence  might  even  be  denied,  if  it  had  not  been  observed  at  the 
period  of  some  severe  epidemics  of  dysentery."  If  Bouchut  refers,  by 
the  term  dysentery,  to  the  ordinary  phenomena  of  that  disease,  his  re- 
mark is  correct ;  but,  as  regards  the  lesions,  it  is  erroneous,  for  colitis 
is  a  common  infantile  malady.  Billard,  after  analyzing  eighty  cases  of 
intestinal  inflammation  in  infants,  says  :  "From  this  calculation,  it  is 
evidently  very  difficult  to  make  a  correct  diagnosis  of  inflammation  of 
the  intestinal  tube  in  sucking  infants,  yet  it  would  seem  as  if  the  proper 
signs  of  enteritis  or  ileitis  were  the  rapid  tym])anitis  of  the  abdomen, 
the  diarrhoea,  accompanied  with  vomiting;  while  in  colitis,  diarrhoea 


INTESTINAL    CATARRH    OF    INFANCY.  719 

alone,  -without  tympanitis,  is  the  most  f"equent."  And  again:  ''In 
consequence  of  the  impossibility  we  have  found  to  exist  of  tracing  with 
exactitude  the  series  of  symptoms  proper  to  inflammation  of  the  differ- 
ent portions  of  the  digestive  tube,  we  shall  content  ourselves  Avith  pre- 
senting an  analytical  sketch  of  the  causes,  symptoms,  and  ordinary 
course  of  inflammation  of  the  mucous  membrane  of  the  intestines  in 
general." 

The  frequent  absence  of  any  pathognomonic  symptom  or  sign,  by 
which  to  determine  the  exact  seat  of  intestinal  inflammation  in  the  in- 
fant, is  admitted  by  recent  observers  as  well  as  Billard. 

The  second  reason  why  intestinal  inflammation  in  the  infant  is  de- 
scribed as  a  single  disease  is,  that  enteritis  and  colitis,  in  the  majority  of 
cases,  coexist.  This  will  be  seen  when  we  come  to  speak  of  the  anatom- 
ical characters. 

In  rural  districts  inftxntile  diarrhoea  is  not  so  prevalent  and  fatal 
as  in  cities.  In  the  fiirming  sections  it  does  not  materially  increase 
the  death-rate,  and  it  is,  therefore,  not  so  important  a  malady  as  in 
cities.  In  cities  it  largely  increases  the  aggregate  of  deaths.  Espe- 
cially fatal  is  that  form  of  it  which  is  known  as  the  summer  epidemic, 
as  is  seen  by  the  mortuary  records  of  any  large  city.  Thus  in  New 
York  City  during  1882  the  deaths  from  diarrhoea  reported  to  the 
Health  Board,  tabulated  in  months,  w^ere  as  follows : 

Jan      Feb      Mar.     Apr.     May.   June.   July.     Aug.     Sept.     Oct.      Nov.    Dec. 
Under  five  vears  .  34       32       50       50       72     231-1533     817     362     195      68      35 
Over  five  years     .   14       15       14       20       15       19     131     149       84       55      31      24 

It  is  seen  that  in  1882  in  New  York  City,  the  deaths  from  diarrhoea 
under  the  age  of  five  years  were  greatly  in  excess  of  the  number  during 
the  whole  period  of  life  subsefjuently  to  that  age. 

The  following  statistics  show  how  great  a  destruction  of  life  this 
malady  causes  even  under  the  surveillance  of  an  energetic  health  board  ; 
and  before  this  board  was  established  it  was  much  greater,  as  I  had 
abundant  opportunities  to  observe.  The  last  annual  report  of  the  New 
York  Board  of  Health  was  made  in  1875,  since  which  time  Aveekly 
bulletins  have  been  issued.  The  deaths  from  diarrhea  at  all  aires  in 
the  last  three  years  in  which  annual  reports  were  issued  were  as  fol- 
lows : 


187.3. 

mi. 

ls75. 

January 

94 

43 

46 

February   . 

84 

34 

52 

March 

93 

40 

58 

April 

114 

47 

45 

May  . 

95 

61 

89 

June 

220 

144 

157 

July  .... 

1514 

1205 

1387 

Autfust 

967 

1007 

1012 

Se|)tem})er 

424 

587 

608 

Ottcber      . 

213 

255 

185 

November 

87 

105 

57 

December 

53 

56 

50 

In  their  annual  re])ort  for  1870  the  Board  state:    '' The  mortality 
from  the  diarrhoeal  affections  amounted  to  2789,  or  33  per  cent,  of  the 


720  INTESTINAL    CATARRH    OF    INFANCY. 

total  deaths  ;  and  of  these  deaths  05  pei*  cent,  occurred  in  children  less 
than  five  years  old,  92  per  cent,  in  children  less  than  two  years  old,  and 
67  per  cent,  in  those  less  than  a  year  old."  Every  year  the  reports  of 
the  Health  Board  furnish  similar  statistics,  but  enouiih  have  been  iriven 
to  show  how  great  a  sacrifice  of  life  infantile  diarrhoea  produces  annu- 
ally in  this  city. 

What  we  observe  in  New  York  in  reference  to  this  disease  is  true 
also,  to  a  greater  or  less  extent,  in  other  cities  of  this  country  and 
Europe,  so  far  as  we  have  reports.  Not  in  every  city  is  there  the  same 
proportionate  mortality  from  this  cause  as  in  New  York,  but  the  fre- 
quency of  infantile  diarrhoea  and  the  mortality  which  attends  it  render 
it  an  important  disease  in,  I  believe,  most  cities  of  both  continents.  In 
country  towns,  whether  in  villages  or  farm-houses,  this  disease  is  com- 
paratively unimportant,  inasmuch  as  few  cases  occur  in  them,  and  the 
few  that  do  occur  are  of  mild  type,  and  consequently  much  less  fatal 
than  in  cities. 

The  comparative  immunity  of  rural  districts  has  an  important  re- 
lation, as  we  will  see,  to  the  hygienic  management  of  these  cases. 

Etiology. — The  diarrhoea  of  infants  is  occasionally  produced  by 
taking  cold.  Infants  insufficiently  protected  by  clothing,  and  exposed 
to  sudden  changes  of  temperature,  or  to  currents  of  air  in  the  apartments 
where  they  reside,  or  heedlessly  exposed  outdoor  by  careless  nurses, 
sometimes  become  affected  with  diarrhoea,  even  of  a  fatal  character. 
They  contract  an  intestinal  inflammation  from  taking  cold,  just  as  other 
infants  may  contract  coryza  or  bronchitis  from  the  same  cause. 

But  the  most  common  causes  of  infantile  diarrhoea  are,  first,  the  use 
of  food  which  is  unsuitable  for  infantile  digestion,  and  which,  therefore, 
acts  as  an  irritant;  and,  secondly,  residence  in  a  foul  atmosphere,  to 
which  we  will  soon  call  attention,  nnd  which  largely  increases  the  per- 
centage of  deaths  in  our  cities  during  the  hot  months.  Diarrhoea  due 
to  taking  cold  occurs  in  all  localities  and  climates,  but  it  is  obviously 
most  common  in  times  of  changeable  weather.  That  due  to  the  use  of 
unsuitable  food  and  foul  air,  occurs  for  the  most  part  in  cities,  and 
much  more  frequently  in  the  summer  season  than  in  the  cool  months, 
as  the  above  statistics  show.  Infantile  intestinal  catarrh,  however  pro- 
duced, presents  nearly  the  same  anatomical  characters,  so  that,  whatever 
its  etiology,  it  is  proper  to  describe  it  as  one  disease,  but  that  form  of  it 
"which  requires  most  elucidation,  and  the  causes  of  which  we  will  con- 
sider in  the  following  pages,  is  that  produced  by  impure  air  and  im- 
proper diet. 

The  prevalence  and  severity  of  infantile  diarrhoea  in  cities,  cor- 
respond closely  with  the  degree  of  atjnosphcric  heat,  as  may  be  inferred 
from  the  foregoing  statistics.  In  New  York  this  disease  begins  in  the 
month  of  May — earlier  in  some  years  than  in  others — in  a  few  scattered 
cases,  commonly  of  a  mild  type.  Cases  become  more  and  more  numer- 
ous and  severe  as  the  weather  grows  warmer  until  July  and  August, 
when  the  diarrhoea  attains  its  maximum  prevalence  and  severity.  In 
these  two  months  it  is  by  far  the  most  frequent  and  fatal  of  all  the  dis- 
eases in  cities.  In  the  middle  of  September  new  patients  begin  to  be 
less  common,  and  in  the  latter  part  of  this  month  and  subsequently  new 


ETIOLOGY.  721 

cases  do  not  occur,  unless  under  unusual  circumstances  which  favor  the 
development  of  this  malady.  In  New  York  a  considerable  number  of 
deaths  of  infants  occur  from  diarrhoea  in  October.  October  is  not  a 
hot  month  in  our  latitude — its  average  temperature  is  lower  than  that 
of  ISIay — and  yet  the  mortality  from  this  disease  is  considerably  larger 
in  the  former  than  in  the  latter  month.  This  fact,  which  seems  to  show 
that  the  pi'evalence  of  the  summer  diaridioea  does  not  correspond  with 
the  degree  of  atmospheric  heat,  is  readily  explained.  The  mortality  in 
October,  and  indeed  in  the  latter  part  of  September,  is  not  that  of  new 
cases,  but  is  mainly  of  inflmts,  as  I  have  observed  every  year,  Avho  con- 
tract the  disease  in  July  or  August  or  earlier,  and  linger  in  a  state  of 
emaciation  and  increasing  weakness  till  they  finally  succumb,  some  even 
in  cool  weather. 

The  fact  is  therefore  undisputed,  and  is  universally  admitted,  that  the 
summer  season,  stated  in  a  general  way,  is  the  cause  of  this  annually 
recurring  diarrhoeal  epidemic,  but  it  is  not  so  easy  to  determine  what 
are  tiie  exact  causative  conditions  or  agents  Avhich  tlie  summer  weather 
brings  into  activity.  That  atmospheric  heat  does  not  in  itself  cause  the 
diarrhoea  is  evident  from  the  fact  that  in  rural  districts  there  is  the 
same  intensity  of  heat  as  in  cities,  and  yet  the  summer  complaint 
does  not  occur.  The  cause  must  be  looked  for  in  the  state  of  the  atmos- 
phere engendered  by  heat  where  unsanitary  conditions  exist,  as  in  large 
cities.  Moreover,  observations  show  that  the  noxious  effluvia  Avith 
which  the  air  becomes  polluted  under  such  circumstances  constitute  or 
contain  the  morbific  agent.  Thus,  in  one  of  the  institutions  of  this  city 
a  few  years  since,  on  ^lay  10,  which  happened  to  be  an  unusually  warm 
day  for  this  month,  an  offensive  odor  was  noticed  in  the  wards,  which 
was  traced  to  a  large  manure-heap  that  was  being  upturned  in  an  adja- 
cent garden.  On  this  day  four  young  children  were  severely  attacked 
by  diarrhoea,  and  one  died.  Many  other  examples  might  be  cited 
showing  how  the  foul  air  of  the  city  during  the  hot  months,  when  animal 
and  vegetable  decomposition  is  most  active,  causes  diarrhoea.  Several 
years  since,  while  serving  as  sanitary  inspector  for  tlie  Citizens'  Asso- 
ciation in  one  of  the  city  districts,  my  attention  Avas  particularly  called 
to  one  of  the  streets,  in  Avhich  a  house-to-house  visitation  disclosed  the 
fact  that  nearly  every  infant  between  two  avenues  had  diarrhoea,  and 
usually  in  a  severe  form,  not  a  few  dying.  This  street  was  compactly 
built  with  wooden  tenement-houses  on  each  side,  and  contained  a  donse 
population,  mainly  foreigners,  poor,  ignorant,  and  filthy  in  their  habits. 
It  had  no  sewer,  and  the  refuse  of  the  kitchens  and  bed-chanibors  was 
thrown, into  the  street,  where  it  accumulated  in  heaps.  Water  trickled 
down  over  the  sidewalks  from  the  houses  into  the  gutters  or  was  thrown 
out  as  slops,  so  that  it  kept  up  a  constant  moisture  of  the  refuse  matter 
which  covered  the  street,  and  promoted  the  decay  of  the  animal  and 
vegetable  substances  which  it  contained.  The  air  in  the  domiciles  and 
street  under  such  conditions  of  impurity  was  necessarily  foul  in  the 
extreme,  and  stifling  during  the  hot  days  and  nights  of  July  and  August; 
and  it  was  evidently  the  important  factor  in  producing  the  numerous 
and  severe  diarrhoeal  cases  which  Avere  in  these  domiciles. 

In   another  locality,   occupied  by  tripe-dealers  and  a  low  class  of 

4G 


722         IXTESTINAL  CATARRH  OF  INFANCY. 

butchers  who  carried  on  fat-  and  bone-boiling  at  night,  the  air  was  so 
foul  after  dark  that  the  peculiar  impurity  which  tainted  it  could  be  dis- 
tinctly noticed  in  the  mouth  for  a  considerable  time  after  a  night  visit. 
In  the  street  where  these  nuisances  existed  and  in  adjacent  streets  the 
summer  diarrluea  was  very  prevalent  and  destructive  to  human  life. 
Murchison  states  that  twenty  out  of  twenty-five  boys  were  affected  with 
purging  and  vomiting  from  inhaling  the  effluvia  from  the  contents  of  an 
old  drain  near  their  school-room.  Physicians  arc  familiar  with  a  similar 
fact  showing  this  purgative  effect  of  impure  air — that  the  atmosphere  of 
a  dissecting-room  often  causes  diarrhoea  in  those  otherwise  healthy. 

The  exact  nature  of  the  deleterious  agent  or  agents  in  foul  air  which 
cause  the  diarrlaca,  whether  they  be  gases  or  organisms,  has  not  been 
fully  deterniiued ;  but  at  a  recent  meeting  of  the  Berliner  Med.  Gesell- 
schaft,  A.  Baginsky  made  a  report  on  the  bacilli  of  cholera  infantum, 
which  he  states  he  has  found  both  in  the  dejections  and  in  the  intestinal 
mucous  membrane  in  the  bodies  of  those  who  have  perished  with  this 
disease.  In  the  stools,  along  with  numerous  other  organisms,  Baginsky 
states  that  he  found  masses  of  zooghea,  and  the  same  organisms  he 
detected  on  the  surface  of  the  small  intestines,  and  could  trace  their 
wanderings  as  far  as  the  submucous  tissue.^  But  it  is  evidently  very 
difficult  to  determine  whether  such  organisms  sustain  a  causative  rela- 
tion to  diarrhoea  or  spring  into  existence  in  consequence  of  the  foul 
secretions  and  decomposing  fecal  matters  which  are  ])resent. 

Tiie  impurities  in  the  air  of  a  large  city  are  very  numerous.  Among 
those  of  a  gaseous  nature  are  sulphurous  acid,  sulphuric  acid,  sulphur- 
etted hydrogen ;  various  gases  of  the  carbon  group,  as  carbonic  acid, 
carburetted  hydrogen,  and  carbonic  oxide ;  gases  of  the  nitrogen  group, 
as  the  acetate,  sulphide,  and  carbonate  of  ammonium,  nitrous  and  nitric 
acids ;  and  at  times  compounds  of  phos|)liorus  and  chlorine  (Parkes). 
A  theory  deserving  consideration  is  that  certain  gaseous  impurities 
found  in  the  air  form  purgative  combinations.  D.  F.  Lincoln,  in  his 
interesting  paper  on  the  atmosphere  in  the  Ci/dopcedia  of  Medicine^ 
writes  in  regard  to  sulphuretted  hydrogen :  "  When  in  the  air,  freely 
exposed  to  the  contact  of  oxygen,  it  becomes  sulphuric  acid.  Sulphide 
of  ammonium  in  the  same  circumstances  becomes  a  sulphate,  which, 
encountering  common  salt  (chloride  of  sodium),  produces  sulphate  of 
sodium  and  chloride  of  ammonium.  The  sulphates  form  a  characteristic 
ingredient  of  the  air  in  manufacturing  districts."  The  sulphates,  we 
know,  are  for  the  most  part  purgatives,  but  Avhether  they  or  other 
chemical  agents  exist  in  the  respired  air  in  sufficient  quantity  to  disturb 
the  action  of  the  intestines,  even  where  atmospheric  impurities  are  most 
abundant,  is  problematical  and  uncertain. 

Again,  the  solid  impurities  in  the  air  of  a  large  city  are  very  numer- 
ous, as  any  one  may  observe  by  viewing  a  sunbeam  in  a  darkened  room, 
which  is  made  visible  by  the  numerous  particles  floating  in  it.  These 
particles  consist  largely  of  organic  matter,  which  sometimes  has  been 
carried  a  long  distance  by  the  Avind.  The  remarkable  statement  has 
been  made  that  in  the  air  of  Berlin  organic  forms  have  been  found  of 

1  AUegem.  Wion.  Mediz.  Zeitiing,  Nov.  0,  1»83. 


ETIOLOGY.  723 

African  production.  Ehrenberg  discovered  fragments  of  insects  of  vari- 
ous kinds — rliizopods,  tardigrades,  polygastrics,  etc. — which,  existing  in 
considerable  quantity  and  inhaled  in  hot  weather,  when  decomposition 
and  fermentation  are  most  active,  may  be  deleterious  to  the  system. 
Monads,  bacteria,  vibriones,  amorphous  dust  containing  spores  which 
retain  their  vitality  for  months,  are  among  the  substances  found  in  the 
air  of  cities.  The  Avell-known  hazy  appearance  of  the  atmosphere 
resting  over  a  large  city  like  New  York  when  viewed  from  a  distance  is 
due  to  the  gaseous  and  solid  impurities  with  Avhich  the  air  is  so  abun- 
dantly supplied — impurities  which  assume  importance  in  pathological 
studies,  since  minute  organisms  are  now  believed  to  cause  so  many  dis- 
eases the  etiology  of  which  has  heretofore  been  obscure.  With  our 
present  knowledge  we  must  be  content  with  the  general  statement  that 
impure  air  is  one  of  the  two  important  factors  which  cause  summer 
diarrhoei,  without  being  able  to  state  positively  which  of  the  elements 
in  the  air  are  most  instrumental  in  causing  this  result.  But  the  theory 
is  plausible  that  minute  organisms  rather  than  chemical  products  are  the 
chief  cause.  Henoch,  of  Berlin,  writing  upon  this  subject,  calls  atten- 
tion to  the  disease  known  as  intestinal  mycosis,  its  prominent  symptom 
being  a  severe  diarrhoea  produced  by  eating  diseased  meat  containing  a 
fungus.  He  believes  that  "a  portion  of  the  fungus  not  destroyed  by 
the  gastric  juice  settles  upon  different  parts  of  the  intestine,  and  there 
produce?  its  effects  ;"  and  he  adds,  ''At  present,  however,  we  can  regard 
the  mykotic  theory  of  cholera  infantum  only  a.s  a  very  probable  hypoth- 
esis. There  is  no  doubt  that  high  atmosphei'ic  temperature  increases 
the  tendency  to  fermentation  dyspepsias  which  is  present  in  imperfectly 
nourished  children  at  all  seasons,  and  causes  them  to  appear  not  only 
epidemically,  but  also  in  an  extremely  acute  form  which  is  not  frequent 
nri  ler  ordinary  circumstances.  This  would  lead  to  the  conclusion  that. 
in  addition  to  the  heat,  infectious  germs  are  present,  which,  being  devel- 
oped in  great  masses  by  the  former,  enter  the  stomach  with  the  food." 
The  fungus  theory  of  the  causative  relation  of  atmospheric  heat  to  the 
diarrlueiof  the  summer  season,  as  thus  explained  by  Ilenoch,  commands 
the  readier  assent  since  it  comports  with  the  well-known  facts  relating 
to  the  etiology  of  the  summer  complaint.  This  disease,  as  we  have  seen, 
is  most  prevalent  and  fatal  under  precisely  those  conditions  of  dense 
population,  filthy  domiciles  and  streets,  and  atmospheric  heat  ■which  are 
favorable  for  the  development  of  low  organisms. 

In  those  portions  of  our  cities  which  are  occupied  by  the  poor,  more 
than  anywhere  else,  those  conditions  prevail  which  render  the  atmos- 
phere deleterious.  One  accustomed  to  the  pure  air  of  the  country 
would  scarcely  believe  how  stifling  and  poisonous  the  atmosphere  be- 
comes during  the  hot  summer  days  and  close  summer  nights  in  and 
around  the  domiciles  in  the  poor  (piarters  of  the  city.  Among  the  causes 
of  this  foul  air  may  be  mentioned  too  dense  a  population,  the  occupancy 
of  small  rooms  by  large  families,  rigid  economy  and  ceaseless  endeavor 
to  make  ends  meet,  so  that  in  the  absorbing  interest  sanitary  require- 
ments are  sadly  neglected.  Adults  of  such  families,  and  children  of 
both  sexes  as  soon  as  they  are  old  enough,  engage  in  laborious  and  often 
llthy  occupations.     Many  of  them  seldom  bathe,  and  they  often  wear 


72-4         INTESTINAL  CATARRH  OF  INFANCY. 

for  (lays  the  same  undergarments,  foul  with  persph-ation  and  dirt.  The 
intemperate,  vicious,  and  indolent,  who  always  aljound  in  the  quarters 
of  the  city  poor,  are  notoriously  filthy  in  their  habits  and  add  to  the 
insalubrity  by  their  presence.  Chihlrou  old  enough  to  be  in  the 
streets  and  adults  aAvay  at  their  occupations  escape  to  a  great  extent 
the  evil  cfiects  of  impure  air,  but  the  infantile  population  always  suifer 
severely. 

Every  physician  who  has  witnessed  the  summer  diarrhoea  of  infants  is 
aware  of  the  fact  that  the  mode  of  feeding  has  much  to  do  with  its  occur- 
rence. A  large  proportion  of  those  who  each  summer  fill  victims  to  it 
would  doubtless  escape  if  the  feeding  were  exactly  proper.  In  New 
York  City  facts  like  the  following  are  of  common  occurrence  in  the 
practice  of  all  physicians  :  Infants  under  the  age  of  eight  months,  if 
bottle-fed,  nearly  always  contract  diarrhcea,  and  usually  of  an  obstinate 
character,  during  the  summer  months.  The  younger  the  infint,  the 
less  able  is  it  to  digest  any  other  food  than  breast-milk,  and  the  more 
lialile  is  it  therefore  to  suffer  from  diarrhoea  if  bottle-fed.  In  the  insti- 
tutions nearly  every  bottle-fed  infant  under  the  age  of  four  or  even  six 
months  dies  in  the  hot  months  with  symptoms  of  indigestion  and  intes- 
tinal catarrh,  while  the  wet-nursed  of  the  same  ages  remain  well. 
Sudden  weaning,  the  sudden  substitution  of  cow's  milk  or  any  artifi- 
ciall}^  prepared  food  in  place  of  breast-milk  in  hot  weather,  almost  always 
produces  diarrhoea,  often  of  a  severe  and  fatal  nature.  Feeding  an  infiint 
in  the  hot  months  with  indigestible  and  improper  food,  as  fruits  with 
seeds  or  the  ordinary  table  food  prepared  in  such  a  Avay  that  it  over- 
taxes the  digestive  function  of  the  infant,  causes  diarrhoea,  and  not  in- 
frequently that  severe  form  of  it  which  Avill  be  described  under  the  term 
cholera  infantum.  Many  obstinate  cases  of  the  summer  complaint  begin 
to  improve  under  change  of  diet,  as  by  the  substitution  of  one  kind  of 
milk  for  anotlier  or  tlie  return  of  the  infant  to  the  breast  after  it  has 
been  temporarily  withdrawn  from  it.  It  is  a  common  remark  in  the 
families  of  the  city  poor  that  the  second  summer  is  the  period  of  greatest 
danger  to  infants.  This  increased  liability  of  infants  to  contract  diar- 
rhcea in  the  second  summer  is  due  to  the  fact  that  most  infants  in  their 
second  year  are  table-fed,  while  in  the  first  year  they  are  wet-nursed. 
Sucli  facts,  with  which  all  physicians  are  familiar,  show  how  important 
the  diet  is  as  a  factor  in  causing  the  summer  complaint. 

Occasionally,  from  continued  ill-health,  the  milk  of  the  mother  or 
wet-nurse  does  not  agree  with  the  nursling.  Examined  with  the  micro- 
scope, it  is  found  to  contain  colostrum.  Under  such  circumstances  if  a 
healthy  wet-nurse  be  employed  the  diarrhoea  ceases.  It  is  very  im- 
portant tliat  any  woman  furnishing  breast-milk  to  an  infant  should  lead 
a  quiet  and  regular  life,  with  regular  meals  and  sleep.  R.  B.  Gilbert^ 
relates  striking  cases  in  which  venereal  excesses  on  the  part  of  wet- 
nurses  were  immediately  followed  by  fatal  diarrhoea  in  the  infants  which 
they  suckled. 

One  not  a  resident  w^ould  scarcely  be  able  to  appreciate  the  difficulty 
which  is  experienceil  in  a  large  city  in  obtaining  proper  diet  for  young 

1  L(juisville  Med.  Journal,  Aug.  10,  1882. 


ETIOLOGY.  725 

children,  especially  those  of  such  an  age  that  they  require  milk  as  the 
basis  of  their  food.  Milk  from  cows  stabled  in  the  city  or  having  a 
limited  pasturage  near  the  city,  and  fed  up(m  a  mixture  of  hay  with 
garden  and  distiller}^  products,  the  latter  often  largely  predominating,  is 
unsuitable.  It  is  deficient  in  nutritive  properties,  prone  to  fermenta- 
tion, and  from  microscopical  and  chemical  examinations  which  have 
been  made  it  appears  that  it  often  contains  deleterious  ingredients.  If 
milk  be  obtained  from  distant  farms  where  pasturage  is  fi'esh  and  abun- 
dant— and  in  New  York  City  this  is  the  usual  source  of  the  supply — 
considerable  time  elapses  before  it  is  served  to  customers,  so  that,  par- 
ticularly in  the  hot  months  of  July  and  August,  it  frequently  has  begun 
to  undergo  lactic  acid  fermentation  Avhen  the  infants  receive  it.  That 
dispensed  to  families  in  the  morning  is  the  milking  of  the  previous 
morning  and  evening.  The  use  of  this  milk  in  midsummer  by  infants 
under  the  age  of  ten  months  frequently  gives  rise  to  more  or  less 
diarrhoea. 

The  ill-success  of  feeding  with  cow's  milk  has  led  to  the  preparation 
of  various  kinds  of  food  w'hich  the  shops  contain,  but  no  dietetic  prepa- 
ration has  yet  appeared  which  agrees  so  well  with  the  digestive  function 
of  the  infant  as  breast-milk,  and  is  at  the  same  time  sufficiently  nutritive 

In  New  York  City  improper  diet,  unaided  by  the  conditions  which 
hot  weather  produces,  is  a  common  cause  of  diarrlupa  in  young  infants, 
for  at  all  seasons  we  meet  with  this  diarrhoea  in  infants  who  are  bottle- 
fed  ;  but  when  the  atmospheric  conditions  oi^  hot  weather  and  the  use 
of  food  unsuitable  for  the  age  of  the  inflint  arc  both  present  and  opera- 
tive, tliis  diarrhoea  so  increases  in  frequency  and  severity  that  it  is 
proper  to  designate  it  the  summer  epidemic  of  the  cities.  Several  years 
since,  before  the  New  York  Foundling  Asylum  was  established,  the 
foundlings  of  New  Y'ork,  more  than  a  thousand  annually,  were  taken 
to  the  almshouse  on  Blackwell's  Island  and  consigned  to  the  care  of 
pauper-women,  wlio  were  mostly  old,  infirm,  and  filthy  in  their  habits 
and  apparel.  Their  beds,  in  which  the  foundlings  were  also  placed 
alongside  of  them,  Avere  seldom,  clean,  not  properly  aired  and  washed, 
and  under  the  beds  were  various  garments  and  utensils  which  these 
pauper-women  had  brought  with  them  as  their  sole  property  from  their 
miserable  abodes  in  the  city.  With  such  surroundings,  the  air  which 
tiiese  infants  breathed  day  and  night  manifestly  contained  poisonous  ema- 
nations; while  their  diet  was  e([ually  improper,  for  it  Avas  prei)ared  by 
these  women  fVom  such  milk  and  firinaceous  food  as  were  furnished  the 
almshouse.  When  assigned  to  duty  in  the  almshouse,  this  service  being 
at  that  time  a  branch  of  Charity  Hospital,  I  was  informed  that  all  the 
foundlings  died  before  the  age  of  two  months ;  one  only  was  ])ointe(l  out 
as  a  curiosity  wliich  had  been  an  exception  to  the  rule.  The  disease  of 
which  they  perished  Avas  diarrhoea,  and  this  malady  in  the  summer 
months  was  es])ecially  severe  and  rapidly  fital.  The  unjjleasant  e\])eri- 
ences  in  this  institution  furnished  additional  evidence,  were  any  wanting, 
that  foul  air  and  improper  diet  are  the  two  important  factors  in  causing 
the  summer  diarrhfca  of  infants.  Since  that  beneficial  charity,  the  New 
York  Foundling  Asylum,  in  East  Sixty-eighth  Street,  came  into  exist- 


726  IXTESTINAL    CATARRH    OF    INFANCY. 

encc,  providing  jiure  air  and,  for  a  considerable  proportion  of  the  found- 
lings, breast-milk,  many  of  these  waifs  have  been  rescued  from  death. 

Age. — Age  is  a  predisposing  cause  of  diarrhoea,  since  most  cases 
occur  under  the  age  of  three  years.  A  large  majority  of  the  summer 
diarrhcras  of  the  cities  occur  under  the  age  of  two  years.  The  following 
table  embraces  all  the  cases  that  came  to  one  of  the  city  dispensaries 
during  my  service  between  the  months  of  May  and  October,  inclusive ; 

Age.  Cases. 

5  months  or  under      ........  ,58 

5  months  to  12  months        .         .  ......     212 

12  months  to  18  months        ........     174 

18  months  to  24  months        ........       93 

24  months  to  86  months        .         .  .         .  ...       36 

Total.  .         .         .         • 573 

Dentition. — Statistics  show  that  by  far  the  largest  numl)er  of  cases 
occur  during  the  period  of  first  dentition  ;  hence  the  prevalent  ojjinion 
amoiiii  families  that  dentition  causes  the  diarrhoea.  It  is  the  common 
belief  among  the  poor  of  New  York  that  diarrhoea  occurring  during 
dentition  is  conservative,  and  should  not  be  checked.  They  believe  that 
an  infant  cutting  its  teeth  suffers  less,  and  may  be  saved  from  serious 
illness,  if  it  have  frequent  stools.  Every  summer  I  see  infants  reduced  to 
a  state  of  imminent  dano-er  through  the  continuance  of  diarrhcx^a  during 
several  weeks,  nothing  having  been  done  to  check  it  in  consequence  of  this 
absurd  belief.  The  progressive  loss  of  flesh  and  strength  and  wasting 
of  the  features  do  not  excite  alarm,  under  the  blinding  influence  of  this 
theory,  till  the  diarrhoea  has  continued  so  long  and  become  so  severe 
that  it  is  with  difficulty  conti'olled,  and  the  patient  is  in  a  state  of  real 
danger  when  the  physician  is  first  summoned.  The  following  statistics, 
which  comprise  cases  occurring  during  my  service  in  one  of  the  city 
dispensaries,  sliow  the  preponderance  of  cases  during  the  age  Avhen 
dental  evolution  is  occurring : 

Cases. 

No  teeth  and  no  marked  turgescence  of  gums      ....  47 

Cutting  incisors    ..........  1CK5 

Cutting  anterior  molars        ........  41 

Cutting  canines    ..........  40 

Cutting  last  molars       .........  20 

All  the  teelh  cut 28 

Total 282 

It  so  happens  that  the  period  of  dental  evolution  corresponds  with 
that  of  the  most  vapid  development  and  the  greatest  functional  activity 
of  the  gastric  and  intestinal  follicles,  and  the;  jiredisposition  which  exists 
to  diarrhceal  maladies  at  this  age  must  be  attributed  to  this  cause  rather 
than  to  dentition. 

Sy.mi'TOMS. — The  intestinal  catarrh  of  infancy  commonly  begins 
gradually  with  languor,  fretfulness,  and  slight  febrile  movement.  The 
diarrhoea  at  first  usually  attracts  little  attention  from  its  mildness.  The 
stools,  Avhile  they  are  thinner  than  natural,  vary  in  appearance,  being 
yellow,  brown,  or  green.      Infants  Avith  milk  diet  usually  pass  green 


SYMPTOMS.  727 

and  acid  stools  containing  particles  of  undigested  casein.  The  tongue 
in  the  commencement  of  the  attack  is  moist  and  covered  ^vith  a  sliirht 
fiir.  At  a  more  advanced  stage  it  may  be  moist,  but  is  often  dry,  and 
in  dangerous  forms  of  the  malady,  accompanied  by  prostration,  the 
buccal  surface  is  red  and  the  gums  more  or  less  swollen  and  sometimes 
ulcerated.  Vomiting  is  common.  It  may  commence  simultaneously 
with  tlie  diarrhcEa,  especially  when  food  that  is  unusually  indigestible 
and  irritating  to  the  stomach  has  been  given,  but  more  frequently  this 
symptom  does  not  appear  until  the  diarrhoea  has  continued  a  few  days. 
I  preserved  memoranda  of  the  date  Avhen  vomiting  began  in  the  cases 
treated  in  two  consecutive  years,  and  found  that  ordinarily  it  was 
toward  the  close  of  the  first  week.  When  it  is  an  early  and  prominent 
symotom  it  appears  to  be  due  to  the  presence  in  the  stomach  of  imper- 
fectly digested  or  fermented  and  acid  food,  v.diich,  when  ejected,  gives  a 
decidedly  acid  reaction  Avith  appropriate  tests.  It  contains  coagulated 
casein  and  undigested  particles  of  whatever  food  has  been  given.  In 
many  patients  the  progressive  loss  of  flesh  and  strength  is  largely  due 
to  the  indigestion  and  vomiting  by  which  the  food,  which  is  so  much  re- 
quired for  proper  nourishment,  is  lost. 

Emesis  occurring  at  a  late  stage  of  infantile  diarrhoea  is  often  due  to 
commencing  spurious  hydrocephalus,  which  is  not  an  infrequent  com- 
plication, as  we  will  see,  of  protracted  cases.  Perhaps  when  a  late  symp- 
tom it  may  sometimes  have  an  umemic  origin,  for  the  urine  is  usually 
quite  scanty  in  advanced  cases.  It  seems  probable,  however,  that  dele- 
terious effects  from  non-elimination  of  urea  are  to  a  considerable  extent 
prevented  by  the  diarrhoea. 

The  fecal  evacuations  may  remain  nearly  uniform  in  appearance 
during  the  disease,  but  in  many  patients  they  vary  in  color  and  con- 
sistence at  different  periods.  In  the  same  case  they  may  be  brown  and 
offensive  at  one  time,  green  at  another,  and  again  they  may  contain 
masses  of  a  putty-like  appearance,  the  partly  digested  casein  or  altered 
epithelial  cells.  The  stools  sometimes  consist  largely  of  mucus,  with 
or  without  occasional  streaks  of  blood,  in<licating  the  predominance  of 
inflammation  in  the  colon.  This  is  the  mucous  diarrhoea  of  Barrier. 
The  stools  are  sometimes  yellow  when  passed,  but  become  green  on  ex- 
posure to  the  air  from  chemical  reaction  due  to  admixture  with  tlie  urine. 

The  character  of  the  alvine  discharges  is  interesting.  In  addition  to 
undigested  casein  I  have  found  e]»ithelial  cells,  single  or  in  clusters 
(souietimes  regtdarly  arranged  as  if  detached  in  mass  fnmi  the  villi), 
fibres  of  meat,  crystalline  formations,  mucus,  and  occasionally  blood,  as 
stated  above.  In  one  instance  I  observed  an  appearance  resembling 
three  or  four  crypts  of  Lieberkiihn  united,  probably  thrown  off  by 
ulceration.  If  the  stools  arc  green,  colored  masses  of  various  sizes,  but 
mostly  small,  are  also  seen  under  the  microscope. 

The  pulse  is  accelerated  according  to  the  severity  of  the  attack.  The 
heat  of  the  surface  is  at  first  generally  increased,  though  but  slightly  in 
ordinary  cases;  but  when  the  vital  powers  begin  to  fail  from  the  con- 
tinuance of  the  diarrhoea  the  warmth  of  the  surface  diminishes.  In 
advanced  cases  a|»proaching  a  fatal  termination  the  face  and  extremities 
are  j)alli  I  and  cool,  and  the  pulse  gradually  becomes  more  frequent  and 


728  liSTTESTINAL    CATARRH    OF    INFANCY. 

feeble.  The  skin  is  usually  dry,  and,  as  already  stated,  the  urinary 
secretion  diminished.  In  severe  cases  attended  by  frequent  alvine  dis- 
charges the  infant  does  not  pass  urine  oftener  than  once  or  twice  daily. 
The  imperfect  action  of  the  skin  and  kidneys  is  noteworthy. 

Protracted  cases  of  diarrlufia  are  freijuently  complicated  by  two  cuta- 
neous eruptions — erythema  extenchng  over  the  perineum  and  fretjuently 
as  far  as  the  thighs  and  lower  part  of  the  abdomen,  due  to  the  acid  and 
irritating  character  of  the  stools  ;  and  boils  upon  the  forehead  and  scalp. 
The  latter  sometimes  extend  to  the  pericranium,  and  in  case  of  recovery 
leave  permanent  cicatrices.  This  furuncular  affection  of  the  scalp  has 
seemed  to  me  useful  in  consequence  of  the  external  irritation  which  it 
causes,  since  it  occurs  at  a  time  when,  on  account  of  the  feeble  heart's 
action  and  languid  circulation,  passive  congestion  of  the  vessels  of  the 
brain  and  meninges  is  liable  to  be  present. 

Patients  Avho  are  weak  and  wasted  in  consequence  of  protracted  diar- 
rhoea, remaining  almost  constantly  in  the  recumbent  position,  often  have 
an  occasional  dry  cough  which  continues  till  the  close  of  life.  It  is  due 
to  hypostatic  congestion  in  the  lungs,  usually  limited  to  the  posterior 
and  inferior  portions  of  the  lobes,  extending  but  a  little  way  into  the 
lungs.  It  is  the  result  of  prolonged  recumbency  with  feeble  heart's 
action  and  feeble  pulmonary  circulation.  Inflmts  reduced  by  chronic 
diseases,  lying  day  after  day  in  their  cribs  with  little  movement  of  their 
bodies,  are  very  liable  to  this  passive  congestion  of  depending  portions 
of  their  lungs,  toward  which  the  blood  gravitates,  and  into  which  but 
little  air  enters  in  consequence  of  their  distance  and  position  and  the 
feeble  respirations.  The  hyperaemia  which  results  is  of  a  passive  char- 
acter, a  venous  congestion,  and  the  affected  lobules  have  a  dusky-red 
color.  This  congestion,  continuing,  soon  results  in  pneumonitis  of  the 
catarrhal  f  )rm,  subacute  and  of  a  low  grade,  for  pulmonary  lobules  in 
which  the  blood  remains  stagnant  soon  exhibit  augmented  cell-prolifera- 
tion, perha])S  from  the  irritating  effects  of  the  elements  of  the  blood  now 
withdrawn  from  the  circulation. 

I  have  made  or  procured  a  considerable  number  of  microscopic  exami- 
nations in  these  cases  of  hypostatic  pneumonia,  and  the  solidification  of 
the  pulmonary  lobules  has  been  found  to  be  due  to  the  exaggerated  de- 
velopment of  the  epithelial  cells  in  the  alveoli,  together  with  venous 
congestion.  The  affected  lobules,  whether  in  a  stage  of  hypostatic  con- 
gestion or  the  more  advanced  stage  of  hypostatic  pneumonitis,  when 
examined  at  the  autopsy,  were  somewhat  softer  than  in  health,  of  dark 
color,  and  many  of  the  lobules  could  be  inflated  by  strong  force  of  the 
breath ;  but  in  protracted  cases  the  alveoli  in  central  parts  of  the 
inflamed  area  resisted  insufflation.  The  lung  in  hypostatic  ])neumonia, 
even  when  it  is  niflated,  still  feels  firmer  between  the  fingers  than  the 
normal  lung. 

Hyj)Ostatic  pneumonia  is  so  common  in  hospitals  for  infixnts  that  some 
physicians  whose  observations  have  been  chiefly  in  such  institutions 
have  almost  ignored  other  forms  of  j)ulmonary  inflammation.  Billard, 
many  years  ago,  wrote  :  "  .  .  .  .  The  pneunu)nia  of  young  chil- 
dren is  evidently  the  result  of  stagnation  of  blood  in  tiieir  lungs. 
Under  these  circumstances  the  blood  may  be  regarded  as  a  kind  of 


SYMPTOMS.  729 

foreign  body."  Of  all  the  chronic  and  exhausting  diseases  of  infancy, 
no  one  has,  according  to  my  observations,  been  so  frec^uently  compli- 
cated by  hypostatic  pneumonia  as  the  disease  which  we  are  considering, 
although  it  does  not  usually  give  rise  to  any  more  prominent  symptom 
than  an  occasional  cough.  Limited  to  a  small  and  almost  immovable 
part  of  the  lung,  it  does  not  ordinarily  accelerate  respiration  or  render 
it  painful,  and  the  cough  is  also  apparently  painless. 

When  ])rogressive  loss  of  flesh  and  strength  has  continued  several 
weeks,  and  the  patient  is  much  exhausted,  another  complication  is  liable 
to  occur,  known  as  spurious  hydrocephalus  or  the  hydrocephaloid  dis- 
ease, the  anatomical  characters  of  which  will  be  described  in  the  proper 
place.  The  commencement  of  spurious  hydrocephalus  is  announced  by 
gradually  increasing  drowsiness,  perhaps  preceded  by  a  period  of  unusual 
fretfulness.  Vomiting  and  rolling  the  head  are  occasional  early  symp- 
toms of  this  complication.  As  the  drowsiness  increases  the  pupils 
become  less  sensitive  to  light  than  in  their  normal  state,  and  are  usually 
contracted.  ^Yhen  the  drowsiness  becomes  profound  and  constant,  the 
pupils  remain  contracted  as  in  sound  sleep  or  in  opium  narcotism.  The 
functional  activity  of  the.  organs  is  now  also  diminished,  the  vomiting 
ceases,  the  stools  become  less  frequent,  the  buccal  surface  dry,  and  the 
urine  scanty,  while  the  pulse  is  fre([uent  and  feeble.  Spurious  hydro- 
cephalus either  continues  till  death,  or  by  stimulation  the  patient  may 
emerge  from  it.     When  profound  the  usual  result  is  death. 

Although  infantile  diarrhoea  in  its  commencement  may  be  promptly 
arrested  by  ])roper  hygienic  and  medicinal  treatment,  if  it  continue  a 
few  weeks  the  anatomical  changes  which  OL*cur  are  such  that  recovery, 
if  it  take  ])lace,  is  necessarily  slow  and  gradual.  Improvement  is  shown 
by  better  digestion,  fewer  stools,  and  of  better  appearance,  less  frequent 
vomiting,  a  more  cheerful  countenance,  and  the  absence  of  symptoms 
Avhich  indicate  a  complication.  Many  recover  after  days  of  anxious 
watching  and  perha})S  after  many  fluctuations. 

Deatli  may  occur  early  froui  a  suddv'U  aggravation  of  symptoms  and 
rapiil  sinking,  or  the  attack  may  be  so  violent  from  the  first  that  the 
infant  quickly  succumbs;  but  more  frequently  death  takes  place  after  a 
prolonged  sickness.  Little  by  little  the  patient  loses  flesh  and  strength, 
till  a  state  of  marked  emaciation  is  reached.  The  eyes  and  cheeks  are 
sunken,  the  bony  projections  of  the  face,  trunk,  and  limbs  become  prom- 
inent, and  the  skin  lies  in  wrinkles  from  the  wasting.  The  altered 
exi)ression  of  the  face  makes  the  patient  look  older  than  the  actual  age. 
The  joints  in  contrast  with  the  wasted  extremities  seem  enlarged  and  the 
fingers  and  toes  elongated.  The  stools  diminish  in  fre(|uency  from 
diminished  peristaltic  and  vermicular  action,  and  vomiting,  if  ])i-eviously 
])resent,  now  ceases.  A  feebh;,  quick,  and  scarcely  api)reciable  pulse, 
slow  respiration,  and  diminished  inflation  of  the  lungs,  sightless  and 
ccmtracted  pupils,  over  which  the  eyelids  no  longer  close,  announce 
the  near  approach  of  death.  The  drowsiness  increases  a)id  the  limbs 
become  cool,  while  perhaps  the  head  is  hot.  The  infant  no  longer  has 
the  ability  to  nurse,  or  if  bottle-fed  the  food  placed  in  the  mouth  flows 
back,  or  is  swallowed  with  a|)parent  indift'erence.  So  low  is  its  vitality 
that  it  lies  pallid  and  almost  motionless  for  hours  or  even  days  before 


730  intesti:n"al  catarrh  of  infancy. 

death,  and  death  occurs  so  quietly  that  the  moment  of  its  occurrence  is 
scarcely  appreciable. 

Anatomical  Characters. — Since  the  prominent  and  essential 
symptoms  of  the  disease  which  avc  are  considering  pertain  to  the  dio-es- 
tive  apparatus,  it  is  evident  that  the  lesions  which  attend  and  charac- 
terize it  are  to  be  found  in  this  part  of  the  system.  Lesions  elsewhere, 
so  flir  as  they  are  appreciable  to  us,  are  secondaiy  and  not  essential. 
I  have  witnessed  a  large  numlier  of  autopsies  of  infants  who  have  per- 
ished from  diarrhcea,  chiclly  in  institutions,  and  they  have  been  suf- 
ficiently marked  and  uniform  to  enable  us  to  designate  it  an  entero- 
colitis. Several  years  since  I  preserved  records  of  the  autopsical 
appearances  in  the  intestinal  catarrh  of  infants,  most  of  the  cases  beino- 
of  summer  diarrhoea.  The  number  aggregated  eighty-two.  Since 
then  I  have  witnessed  many  autopsies  in  institutions  in  cases  of  this 
disease,  and  the  lesions  observed  were  similar  to  those  in  the  eighty-two 
cases. 

The  question  may  properly  be  asked,  Can  inflammatory  hypememia 
of  the  intestinal  mucous  membrane  be  distinguished  from  simple  con- 
gestion if  there  be  no  ulceration  and  no  appreciable  thickeninof  of  the 
intestine  ?  It  is  possible  that  occasionally  I  have  recorded  as  inflamma- 
tory what  was  siniDly  a  congestive  lesion,  but  I  do  not  think  I  have  in- 
corporated a  sufficient  number  of  such  cases  to  vitiate  tlie  statistics.  In 
a  large  proportion  of  the  cases  there  was  evident  thickening  of  the  in- 
testinal mucous  membrane  or  other  unequivocal  evidence  of  inflamma- 
tion.    The  following  is  an  analysis  of  the  eighty-two  cases : 

The  duodenum  and  jejunum  presented  the  appearance  of  inflammatory 
hyperiemia  in  12  cases.  The  hyperpemia  was  usually  in  patches  of 
variable  extent  or  of  that  form  described  by  the  term  arborescent.  In 
51  cases  the  duodenal  and  jejunal  mucous  membrane  was  pale  and  with- 
out any  other  appearance  characteristic  of  catarrh  or  inflammation.  In 
the  remaining  19  cases  the  appearance  of  the  duodenum  and  jejunum 
was  not  recorded,  so  that  it  was  probably  normal.  On  the  other  hand, 
in  the  ileum  inflammatory  lesions  were  present  as  a  rule.  In  49  cases  I 
found  the  surface  of  the  ileum  distinctly  hyperiemic,  and  in  that  portion 
of  it  nearest  the  ileo-ctecal  valve,  including  the  valve  itself,  the  inflam- 
mation had  evidently  been  the  most  intense,  since  in  this  portion  the 
hyperemia  and  thickening  of  the  mucous  membrane  were  most  marked. 
In  IG  cases  the  surface  of  the  ileum  appeared  nearly  or  quite  normal; 
in  11:  hyperaemia  in  the  small  intestines  in  patches,  streaks,  or  arbo- 
rescence  was  recorded,  but  the  records  do  not  state  in  which  division  of 
the  intestines  they  were  observed. 

Billard,  with  other  observers,  has  noticed  the  frequency  and  intensity 
of  the  inflammatory  lesions  in  entero-colitis  in  the  terminal  portion  of 
the  small  intestines,  and  the  thickening  in  many  cases  of  the  ileo-caecal 
valve,  and  he  asks  whether  tlie  vomiting  which  is  so  common  and  often 
obstinate  in  this  disease  may  not  be  sometimes  due  to  obstruction  to  the 
passage  of  fecal  matter  at  the  valve  in  consequence  of  the  hyperaemia 
and  swelling,  but  has  not  observed  any  retained  fecal  matter  above  it, 
such  as  we  find  in  any  part  of  the  colon,  or  any  other  appearance  which 
indicated  sufficient  obstruction  to  cause  symptoms.     Still,  it  seems  not 


ANATOMICAL    CHARACTERS.  731 

improbable  that  the  reason  why  the  inflammatory  lesions  are  more  pro- 
nounced at  and  immediately  above  the  valve  than  in  other  parts  of  the 
small  intestine  is  that  the  fecal  matter,  so  commonly  acid  and  irritating 
in  this  disease,  is  somewhat  delayed  in  its  passage  downward  at  this  point. 

Small  superficial  circular  or  oval  ulcers  Avere  observed  in  the  ileum  in 
4  cases,  in  2  of  which  they  were  found  also  in  the  lower  part  of  the 
jejunum.  In  1  case  the  records  state  that  ulcers  were  in  the  jejunum, 
but  do  not  mention  whether  they  were  also  in  the  ileum.  In  1  case,  in 
which  there  was  much  thickening  of  the  ileum  next  to  the  ileo-cfecal 
valve,  many  small  granulations  had  sprouted  up  from  the  submucous 
connective  tissue,  so  that  the  mucous  surface  appeared  as  if  studded  with 
small  Avarts. 

Softening  of  the  mucous  membrane  was  also  apparent  in  certain  cases. 
The  firmness  of  its  attachment  to  tlie  parts  underneath  varied  consider- 
ably in  difterent  specimens.  I  was  able  in  cases  in  which  there  was 
considerable  softening  to  detach  readily  the  mucous  membrane  with  the 
nail  or  handle  of  the  scalpel  Avithin  so  short  a  period  after  death  that  it 
was  probable  that  the  change  of  consistence  was  not  cadaveric.  In  some 
cases  the  vessels  of  the  submucous  tissue  Avere  injected  and  this  tissue 
infiltrated. 

In  all  the  cases  except  one  lesions  were  present  indicating  inflammation 
of  the  mucous  membrane  of  the  colon.  In  30  hyper«3mia,  thickening, 
and  other  signs  of  inflammation  extended  o\'er  nearly  or  quite  the  entire 
colon  ;  in  14  the  colitis  was  confined  to  the  descending  portion  entirely 
or  almost  entirely ;  in  28  cases  the  records  state  that  inflammatory 
lesions  Avere  found  in  the  colon,  but  their  exact  location  is  not  men- 
tioned. In  1<S  of  the  autopsies  the  mucous  membrane  of  the  colon  Ava^ 
found  ulcerated. 

Therefore,  according  to  these  statistics — and  autopsies  Avhich  I  liaA'e 
Avitnessed  that  are  not  embraced  in  them  disclosed  similar  lesions — 
colitis  is  present,  alm(jst  Avithout  exception,  in  cases  of  summer  diar- 
rhcua,  associated  Avith  more  or  less  ileitis.  The  ])ortion  of  the  colon 
Avhich  presents  the  most  marked  inflammatory  lesions  is  that  in  and 
immediately  above  the  sigmoid  flexure — that  portion,  therefore,  in 
Avhich  any  fermenting  fecal  matter  has  reached  its  greatest  degree  of 
fermentation,  and  consequently  contains  the  most  irritating  elements, 
and  Avhere,  next  to  the  caput  coli,  it  is  longest  delayed  in  its  passage 
doAvnward. 

The  solitary  glands  of  both  the  large  and  small  intestines  and  Peyer's 
patches  undergo  hyperj^lasia.  In  cases  of  short  duration,  and  in  parts 
of  the  intestine  Avhere  the  inflammatory  action  has  been  mild,  the  solitary 
glands  present  a  vascular  appearance,  like  the  surrounding  membrane, 
and  are  slightly  enlarged.  The  eidargement  is  most  apparent  if  the 
intestine  be  vicAved  by  transmitted  light,  when  not  oidy  are  the  glands 
seen  to  be  swollen,  but  their  central  dark  points  are  distinct.  If  a 
higher  grade  of  intestinal  catarrh  or  a  catarrh  more  protracted  liave 
occurred,  the  volume  of  these  follicles  is  so  increased  that  they  rise 
above  the  common  level  and  present  a  })apillary  appearance.  Peyer's 
patches  are  also   distinct  and  punctate.     The  enlargement  of  Peyer's 


732  INTESTINAL    CATARRH    OF    INFANCY. 

patches,  like  that  of  the  solitary  glands,  is  due  to  hyperplasia,  the  ele- 
mentary cells  being  largely  increased  in  number. 

The  small  ulcers  which,  as  we  have  seen  from  the  above  statistics,  are 
present  in  a  certain  proportion  of  cases  in  the  mucous  membiane  of  the 
colon,  and  more  rarely  in  that  of  the  small  intestine  when  tlie  inilam- 
mation  has  been  protracted  and  of  a  severe  type,  appear  to  occur  in  the 
solitary  glands  and  in  the  mucous  membrane  surrounding  them.  While 
some  of  these  glands  in  a  specimen  are  simply  tumefied,  others  are 
slightly  ulcerated,  and  others  still  nearly  or  quite  destroyed.  The  ulcers 
are  usually  from  one  to  three  lines  in  diameter,  circular  or  oval,  Avith 
edges  slightly  raised  from  infiltration.  liarely,  I  have  seen  minute 
coagula  of  blood  in  one  or  more  ulcers,  and  I  have  also  observed  ulcers 
which  have  evidently  been  larger  and  have  partially  healed.  The  ulcers 
are  more  frequently  found  in  the  descending  colon  than  in  other  por- 
tions of  the  intestines.  When  ulcers  are  present  they  commonly  occur 
in  the  descending  colon,  or  if  occurring  elsewhere  they  are  most  abun- 
dant in  this  situation. 

According  to  my  observations,  these  ulcers  are  found  chiefly  in  infants 
over  the  age  of  six  months — during  the  time,  therefore,  when  there  is 
greatest  functional  activity  and  most  rapid  development  of  the  solitary 
glands.  Peyer's  patches,  though  fre(piently  prominent  and  distinct, 
have  not  been  ulcerated  in  any  of  the  cases  observed  by  me. 

The  appendix  vcrmiforniis  participates  in  the  catarrh  when  it  occurs 
in  the  caput  coli,  its  mucous  membrane  being  hypera^mic  and  thickened. 
In  certain  rare  cases  the  inflammation  is  so  intense  that  a  thin  film  of 
fibrin  is  exuded  in  places  upon  the  surface  of  the  colon.  It  is  liable  to 
be  overlooked  or  washed  awjiy  in  the  examination.  The  rectum  usually 
presents  no  inflammatory  lesions,  or  but  slight  lesions  in  comparison 
with  those  in  the  colon.  It  remains  of  the  normal  pale  color,  or  is  but 
slightly  vascular  in  most  patients,  even  when  there  is  almost  general 
colitis.     Hence  the  infrequency  of  tenesmus. 

As  might  be  expected  from  the  nature  of  the  disease,  the  secretion 
of  mucus  from  the  intestinal  surface  is  augmented.  It  is  often  seen 
forming  a  layer  u])on  the  intestinal  surface,  and  it  appears  in  the  stools 
mixed  with  ej)ithelial  cells  and  sometimes  Avith  blood  and  ])us. 

The  mesenteric  glands  in  cases  which  have  run  the  most  ])rotracted 
course  and  ended  fatally  are  found  more  or  less  enlarged  from  hyper- 
plasia. They  are  frequently  as  large  as  a  pea  or  larger,  and  of  a  light 
color,  the  color  being  due  not  only  to  the  hyperplasia,  but  in  part  to  the 
anaemia.  Occasionally,  Avhen  patients  have  been  much  reduced  from 
the  long  continuance  of  the  diarrhoea,  and  are  in  a  state  of  marked 
cachexia  before  death,  we  find  certain  of  these  glands  caseous. 

The  state  of  the  stomach  is  interesting,  since  indigestion  and  vomiting 
are  so  commonly  present.  I  have  records  of  its  appearance  in  59  cases, 
in  42  of  which  it  seemed  normal,  having  the  usual  pale  color  and  ex- 
hibiting only  such  changes  as  occur  in  the  cadaver.  In  the  remaining 
17  cases  the  stomach  was  more  or  less  hyperpemic,  and  in  8  of  them 
points  of  ulceration  Avere  observed  in  the  mucous  membnino. 

All  j)hysicians  familiar  Avith  this  disease  have  remarked  tlie  fi'c- 
quency  of  stomatitis.     In  protracted  and  grave  cases  it  is  a  common 


ANATOMICAL    CHARACTERS.  733 

complication  The  buccal  surface  in  these  cases  is  more  vascular  than 
natural,  and  if  the  vital  powers  are  much  reduced  superficial  ulcerations 
are  not  infre<:|uent,  oftener  upon  the  gums  than  elsewhere.  The  gums 
are  frequently  spongy,  more  or  less  swollen,  bleeding  readily  when 
rubbed  or  pressed  upon.  Thrush  is  a  couunon  complication  of  pro- 
tracted diarrhoea  in  infants  under  the  age  of  three  or  four  months,  but 
is  infrequent  in  older  infants.  Occurring  in  those  over  the  age  of  six 
or  eight  months,  it  has  an  unfivorable  prognostic  significance,  indi- 
cating a  form  of  diarrhcea  which  commonly  eventuates  in  death. 

Tiie  belief  has  long  been  prevalent  in  the  past  that  the  liver  is  also 
in  fiult.  The  green  color  of  the  stools  was  supposed  to  be  due  to  viti- 
ated bile.  But  usually  in  the  post-mortem  examinations  which  I  have 
made  I  have  found  that  the  green  coloration  of  the  fecal  matter  did 
not  appear  at  the  point  where  the  bile  enters  the  intestines,  but  at  some 
point  below  the  ductus  communis  choledochus  in  the  jejunum  or  ileum. 
The  green  tinge,  at  first  slight,  becomes  more  and  more  distinct  on 
tracing  it  downward  in  the  intestine.  It  appears  to  be  due  to  admix- 
ture of  the  intestinal  secretions  with  the  fecal  matter. 

I  have  notes  of  the  appearance  and  state  of  the  liver  in  32  fatal 
cases.  Nothing  could  be  seen  in  tliese  examinations  Avhich  indicated 
any  anatomical  change  in  this  organ  that  could  be  attrilmted  to  the 
diarrhoeal  inaladv.  The  size  and  weiijrht  of  the  liver  varied  consider- 
ably  in  infants  of  the  same  age,  but  probably  there  was  no  greater  dif- 
ference than  usually  obtains  among  glandular  organs  in  a  state  of 
health.     The  following  was  the  Aveight  of  this  organ  in  20  cases : 

Age.                                                         Weight.  Auo.                                                       "Weight. 

4  \veek-> 5    ounces.         10  months 6J    ounces. 

2  mnnihs 3.V       "  13       "        6  " 

2      " 3i         '  14       "        9  " 

4      >' o'        "  15       "        0  " 

6J       "  15       "        7k        " 


V-o. 

10 

luon 

th; 

13 

14 

15 

15 

15 

16 

19 

20 

23 

9  "  15  "  9.V 

4.V  "  16  '<  6" 

6'  "  19  "  4i 

Oi-  "  20  "  0\ 

8  "  23  "  15 


In  none  of  these  cases  did  the  size,  Aveight,  or  appearance  of  this  organ 
seem  to  be  different  from  that  in  health  or  in  other  diseases,  except  in 
one  in  which  fatty  degeneration  had  occurred,  but  this  was  probably 
due  to  tuberculosis,  which  was  also  present.  In  most  of  these  cases  the 
liver  was  examined  microscopically,  and  the  only  noteworthy  appear- 
ance observed  was  the  variable  amount  of  oil-globules  in  the  hepatic 
cells.  In  some  specimens  the  oil-globules  were  in  excess,  in  others 
deficient,  and  in  others  still  they  were  more  abundant  in  one  part  of  the 
organ  than  in  another.  Little  importance  was  attached  to  these  differ- 
ences in  the  quantity  of  oily  matter. 

Hypostatic  congestion  of  the  posterior  portions  of  the  lungs,  ending 
if  it  continue  in  a  form  of  subacute  catarrhal  pneumonia  and  giving 
rise  to  an  occasional  painless  cough,  has  been  described  in  the  preced- 
ing pages.  The  character  of  the  cough  in  connection  with  the  wasting 
might  excite  suspicions  of  the  presence  of  tubercles  in  the  lungs ;  but 


734  INTESTIXAL    CATARRH    OF    INFANCY. 

tubercles  are  rare  in  this  disease,  and  -when  })resent  I  should  suspect  a 
strong  hereditary  predisposition.    They  occurred  in  only  1  of  the  82  cases. 

Tiie  state  of  the  encephalon  in  those  patients  in  whom  spurious 
hydrocephalus  occurs  is  interesting.  In  protracted  cases  of  diarrhoea 
the  brain  wastes  like  the  body  and  limbs.  In  the  young  infant,  in 
whom  the  cranial  bones  are  still  ununited,  the  occipital  and  sometimes 
the  frontal  bones  become  depressed  and  overhipped  by  the  parietal,  the 
depression  being  of  course  proportionate  to  the  diminution  in  size  of  the 
encephalon.  The  cranium  becomes  quite  uneven.  In  other  children, 
w;ith  the  cranial  bones  consolidated,  serous  effusion  occurs  according  to 
the  degree  of  waste,  thus  preserving  tlie  size  of  tlie  euceijhalon.  The 
effusion  is  chiefly  external  to  the  brain,  lying  over  the  convolutions  from 
the  base  to  the  vertex.  Its  quantity  varies  from  one  or  two  drachms  to 
an  ounce  or  more.  Along  with  this  serous  effusion,  and  antedating  it, 
passive  congestion  of  the  cerebral  veins  and  sinuses  is  also  present. 
This  congestion  is  the  obvious  and  necessary  result  of  the  feebleness  of 
the  heart's  action  and  the  loss  of  brain  substance. 

DiAdNOSis. — In  the  adult  abdominal  tenderness  is  an  important 
diagnostic  symptom  of  intestinal  catarrh,  but  in  the  infant  this  symjitom 
is  lacking  or  is  not  in  general  appreciable,  so  that  it  does  not  aid  in 
diagnosis.  When  the  diagnosis  of  the  disease  is  established,  the  symp- 
toms do  not  usually  indicate  what  part  of  the  intestinal  surface  is  chiefly 
involved,  but  it  may  be  assumed  that  it  is  the  lower  part  of  the  ileum 
and  the  colon.  The  presence  of  mucus  or  of  mucus  tinged  with  blood 
in  the  stools  shows  the  predominance  of  colitis. 

Prognosis. — Although  this  disease  largely  increases  the  death-rate 
of  young  children,  most  cases  can  be  cured  if  proper  hygienic  and 
medicinal  measures  be  early  applied.  It  is  obvious,  from  what  has 
been  stated  in  tlie  foregoing  pages,  that  cholera  infantum  is  the  form 
of  this  malady  which  involves  greatest  danger.  Except  in  such  cases 
there  is  sufficient  forewarning  of  a  fatal  result,  for  if  death  occur  it  is 
after  a  lingering  sickness,  with  fluctuations  and  gradual  loss  of  flesh 
and  strength.  Patients  often  recover  from  a  state  of  great  prostration 
and  emaciation,  provided  that  no  fatal  complications  arise.  The  eyes 
may  be  suid^en,  the  skin  lie  in  folds  from  the  wasting,  the  strength  may 
be  so  exhausted  that  any  other  than  the  recumbent  position  is  impos- 
sible, and  yet  the  patient  may  recover  by  removal  to  the  country,  by 
change  of  weather,  or  by  the  use  of  better  diet  and  remedies.  There- 
fore an  absolutely  unfavorable  prognosis  should  not  be  made  except  in 
cases  that  are  complicated  or  that  border  on  collapse.  The  most  dan- 
gerous symptoms,  except  those  which  indicate  commencing  or  actual 
collapse,  arise  from  the  state  of  the  brain.  Rolling  the  head,  squinting, 
feeble  action  or  permanent  contraction  of  the  pupils,  spasmodic  or 
irregular  movements  of  the  limbs,  indicate  the  near  approach  of  death, 
as  do  also  coldness  of  face  and  extremities  and  inability  to  swallow.  It 
is  obvious  also,  in  making  the  prognosis  in  ordinary  cases,  that  we 
should  consider  the  age  of  the  patient,  and  if  the  diarrhoea  be  that  of  the 
summer  season,  the  state  of  the  Aveather,  the  time  in  the  sunnner,  Avhether 
in  the  beginning  or  near-  its  close,  and  the  surroundings,  especially  in 
reference  to  the  impurity  of  the  air,  as  well  as  the  patient's  condition. 


CHOLERA    INFANTUM.  735 


Cholera  Infantum,  or  Oholeriforni  Diarrhoea. 

This  is  the  most  severe  form  of  infantile  diarrhoea.  It  receives  the 
name  which  designates  it  from  the  violence  of  its  symptoms,  which 
closely  resemble  those  of  xVsiatic  cholera.  It  is,  however,  quite  distinct 
from  that  disease.  It  is  characterized  by  frequent  stools,  vomiting, 
great  elevation  of  temperature,  and  rapid  and  great  emaciation  and  loss 
of  strength.  It  commonly  occurs  under  the  age  of  two  years.  It  some- 
times begins  abruptly,  the  previous  health  having  been  good  ;  in  other 
cases  it  is  preceded  by  the  ordinary  form  of  diarrhcea.  The  stools  have 
been  thinner  than  natural  and  somewhat  moi'e  frequent,  but  not  such  as 
to  excite  alarm,  when  suddenly  they  become  more  frequent  and  watery, 
and  the  parents  are  surprised  and  frightened  by  the  rapid  sinking  and 
real  danger  of  the  infant. 

The  first  evacuations,  unless  there  have  been  previous  diarrhoea,  may 
contain  fecal  matter,  but  subsequently  they  are  so  thin  that  they  soak 
into  the  diaper  like  urine,  and  in  some  cases  they  scarcely  produce  more 
of  a  stain  than  does  this  secretion.  Their  odor  is  peculiar — not  fecal, 
but  must}^  and  offensive ;  occasionally  they  are  almost  odorless.  Com- 
mencing simultaneously  with  the  watery  evacuations,  or  soon  after,  is 
another  symptom,  irritability  of  the  stomach,  which  increases  greatly  the 
prostration  and  danger.  Whatever  drinks  are  swallowed  by  the  infant 
are  rejected  immediately  or  after  a  few  momeuts,  or  retching  may  occur 
without  vomiting.  The  appetite  is  lost  and  the  thirst  is  intense.  Cold 
water  is  taken  with  avidity,  and  if  the  infant  nurse,  it  eagerly  seizes  the 
breast  in  order  to  relieve  the  thirst.  The  tongue  is  moist  at  fir.-t,  and  clean 
or  covered  with  a  light  fur,  pulse  accelerated,  respiration  either  natural 
or  somewhat  increased  in  frequency,  and  the  surface  warm,  but  the  tem- 
perature is  speedily  reduced  in  severe  cases.  The  internal  temperature 
or  that  of  the  blood  is  always  very  high.  In  ordinary  cases  of  cholera 
infantum  the  thermometer  introduced  into  the  rectum  rises  to  or  above 
105°,  and  I  hive  seen  it  indicate  107°.  Although  the  infant  may  be 
restless  at  first,  it  does  not  appear  to  have  any  abdominal  pain  or  ten- 
derness. The  restlessness  is  apparently  due  to  thirst  or  to  that  un- 
pleasant sensation  which  the  sick  feel  when  the  vital  powers  are  rapidly 
reduced.  The  urine  is  scanty  in  proportion  to  the  gravity  of  the  attack, 
as  it  ordinarily  is  when  the  stools  are  frequent  and  watery. 

The  emaciation  and  loss  of  strength  are  more  rapid  than  in  any  other 
disease  which  I  can  recall  to  mind,  unless  in  Asiatic  cholera.  In  a  few 
hours  the  parents  scarcely  recognize  in  the  changed  and  melancholy 
aspect  of  the  infant  any  resemblance  to  the  features  which  it  exhibited 
a  day  or  two  before.  The  eyes  are  sunken,  the  eyelids  and  lips  are 
permanently  open  from  the  feeble  contractile  power  of  the  muscles 
wiiich  close  them,  while  the  loss  of  the  fluids  from  the  tissues  and  the 
emaciation  are  such  that  the  bony  angles  become  more  prominent  and 
the  skin  in  places  lies  in  folds. 

As  the  disease  approaches  a  fatal  termination,  Avhich  often  occurs  in 
two  or  three  days,  the  infant  remains  quiet,  not  disturbed  even  by  the 


l6b  CHOLERA    INFAXTU:\r. 

flies  Avliich  alight  upon  its  face.  Tlio  limbs  and  face  become  cool,  the 
eyes  bleared,  pupils  contracted,  and  the  urine  scanty  or  suppressed.  In 
some  instances,  Avhen  the  patient  is  near  death,  the  respiration  becomes 
accelerated,  either  from  tlie  effect  of  the  disease  upon  the  respiratory 
centres  or  from  pulmonary  congestion  resulting  from  the  feeble  circula- 
tion. As  the  vital  powers  fail  the  pulse  becomes  progressively  more 
feeble,  the  surface  has  a  chunmy  coldness,  the  contracted  pupils  no 
longer  respond  to  light,  and  the  stupor  deepens,  from  which  it  is  impos- 
sible to  arouse  the  infant. 

In  the  more  favorable  cases  cholera  infantum  is  checked  before  the 
occurrence  of  these  grave  symptoms,  and  often  in  cases  which  are  ulti- 
mately fatal  there  is  not  such  a  speedy  termination  of  the  malady  as  is 
indicated  in  the  above  description.  The  choleriform  diarrhoea  abates 
and  the  case  becomes  one  of  ordinary  summer  complaint. 

Anatomical  Characters. — Rilliet  and  Barthez,  who  of  foreign 
writers  treat  of  cholera  inflxntum  at  greatest  length,  describe  it  under 
the  name  of  gastro-intestinal  choleriform  catarrh.  "The  perusal," 
they  remark,  '•  of  anatomico-pathological  descriptions,  and  especially 
the  study  of  the  facts,  show  that  the  gastro-intestinal  tube  in  subjects 
who  succumb  to  this  disease  may  be  in  four  different  states :  (a)  either 
the  stomach  is  softened  without  any  lesion  of  the  digestive  tube;  (/>)  or 
the  stomach  is  softened  at  the  same  time  that  the  mucous  membrane  of 
the  intestine,  and  especially  its  follicular  apparatus,  is  diseased ;  (c)  or 
the  stomach  is  healthy,  while  the  follicular  apparatus  or  the  mucous 
membrane  is  diseased ;  [d)  or,  finally,  the  gastro-intestinal  tube  is  not 
the  seat  of  any  lesion  appreciable  to  our  senses  in  the  present  state  of 
our  knowledge,  or  it  presents  lesions  so  insignificant  that  they  are  not 
sufficient  to  explain  the  gravity  of  the  symptoms. 

"So  far,  the  disease  resembles  all  the  catarrhs,  but  what  is  special 
is  the  abundance  of  serous  secretion  and  the  disturbance  of  the  great 
sympathetic  nerve. 

"  The  serous  secretion,  which  appears  to  be  produced  by  a  perspira- 
tion (analogous  to  that  of  the  respiratory  passages  and  of  the  skin) 
rather  than  by  a  follicular  secretion,  shows,  perhaps,  that  the  elimina- 
tion of  substances  is  eff'ected  by  other  organs  than  the  follicles  ;  perhaps, 
also,  we  ought  to  see  a  proof  that  the  materials  to  eliminate  are  not  the 
same  as  in  simple  catarrh.  Upon  all  these  points  we  are  constrained  to 
remain  in  doubt.     We  content  ourselves  with  pointing  out  the  fact."^ 

On  the  1st  of  August,  1861,  I  made  the  autopsy  of  an  infant  sixteen 
months  old  who  died  of  cholera  infantum  with  a  sickness  of  less  than 
one  day.  The  examination  Avas  made  thirty  hours  after  death.  Nothing 
unusual  was  observed  in  the  brain,  unless  perhaps  a  little  more  than 
the  ordinary  injection  of  vessels  at  the  vertex.  No  marked  anatomical 
change  Avas  observed  in  the  stomach  and  intestines,  except  enlargement 
of  the  patches  of  Peyeras  well  as  of  the  solitary  and  mesenteric  glands. 
Mucous  membrane  pale.  In  this  and  the.  following  cases  there  was 
apparently  slight  softening  of  the  intestinal  mucous  membrane,  but 
whether  it  was  pathological  or  cadaveric  was  uncertain,  as  the  weather 

*  Muladit'S  dos  Enfants. 


ANATOMICAL    CHARACTERS.  737 

"was  very  warm.  The  liver  seemed  healthy.  Examined  by  the  micro- 
scope, it  was  found  to  contain  about  the  normal  number  of  oil-globules. 

The  second  case  was  that  of  an  infant  seven  months  old,  wet-nursed, 
Avho  died  July  2(j,  1862,  after  a  sickness  also  of  about  one  day.  He 
was  previously  emaciated,  but  without  any  marked  ailment.  The  post- 
mortem examination  was  made  on  the  28th.  The  brain  Avas  somewhat 
softer  than  natural,  but  otherwise  healthy.  There  was  no  abnormal 
vascularity  of  the  membranes  of  the  brain,  and  no  serous  effusion  within 
the  cranium.  The  mucous  membrane  of  the  intestines  had  nearly  the 
normal  color  throughout,  but  it  seemed  somewhat  thickened  and  soft- 
ened ;  the  solitary  glands  of  the  colon  were  prominent.  The  patches 
of  Peyer  were  not  distinct. 

In  the  New  York  Protestant  Episcopal  Orphan  Asylum  an  infant 
twenty  months  old,  previously  healthy,  was  seized  with  cholera  infantum 
on  the  25th  of  June,  1864.  The  alvine  evacuations,  as  is  usual  with 
this  dise  ise,  were  frequent  and  watery,  and  attended  by  obstinate  vomit- 
ing. Dc-ath  occurred  in  slight  spasms  in  thirty-six  hours.  The  excit- 
ing cause  was  probably  the  use  of  a  few  currants  Avhich  were  eaten  in  a 
cake  the  day  before,  some  of  which  fruit  Avas  contained  in  the  first  evac- 
uations. The  brain  Avas  riot  examined.  The  only  pathological  changes 
whiah  AA^ere  observed  in  the  stomach  and  intestines  Avere  sliirhtly  vas- 
cular  patches  in  the  small  intestines  and  an  unusual  prominence  of  the 
solitai-y  glands  in  the  colon.  The  glands  resembled  small  beads  im- 
bedded in  the  mucous  membrane.  The  lung^  in  the  above  cases  Aver© 
healthy,  excepting  hypostatic  congestion. 

Since  the  date  of  these  autopsies  I  have  made  others  in  cases  Avhich 
terminated  fatally  after  a  brief  duration,  and  have  nniformly  found  sim- 
ilar lesions — to  Avit,  the  gastro-intestinal  surface  either  Avithout  vascu- 
larity or  scantily  A'ascular  in  streaks  or  patches,  sometimes  presenting  a 
whitish  or  soggy  appearance  and  somcAvhat  softened,  Avhile  the  solitary 
glands  were  enlarged  so  as  to  be  prominent  upon  the  surface.  In  cases 
Avhich  continue  longer  evident  inflammatory  lesions  soon  appear  which 
are  identical  Avith  those  Avhich  have  already  been  described  in  our 
remarks  relating  to  the  ordinary  form  of  diarrhoea. 

During  my  term  of  service  in  the  Ncav  York  Foundling  Asylum  in 
the  summer  of  1884,  an  infant  died  after  a  brief  illness  Avith  all  the 
symptoms  of  cholera  infantum,  and  the  intestines  Avere  sent  to  William 
H.  Welch,  now  of  Johns  Hopkins  Hospital,  for  microscopic  examina- 
tion. His  report  Avas  as  folloAvs  :  "  I  found  undoubted  evidence  of  acute 
inflammation.  There  Avas  an  increased  number  of  small,  round  cells 
(leucocytes)  in  the  mucous  and  submucous  coats.  This  accumulation 
of  new  cells  Avas  most  abundant  in  and  around  the  solitary  follicles,  Avhich 
were  greatly  swollen.  Clumps  of  lymphoid  cells  Avere  found  extending 
even  a  little  into  the  muscular  coat.  The  epithelial  lining  of  the  intes- 
tine Avas  not  demonstrable,  but  this  is  usually  the  case  Avith  ])ost-mortem 
specimens  of  human  intestine,  and  justifies  no  inferences  as  to  patho- 
logical changes.  The  glands  of  Lieberkiihn  Avere  rich  in  the  so-called 
goblet-cells,  and  some  of  the  glands  were  distended  with  mucus  and 
desquamated  epithelium,  so  as  to  present  sometimes  the  appearance  of 
little  cysts.     This  Avas  observed  especially  in  the  neighborhood  of  the 

47 


738  .  C  H  0  L  E  R  A    I  X  F  A  N  T  U  M  . 

solitary  follicles.  The  bloodvessels,  especially  the  veins  of  the  suli- 
raucous  coat,  Avere  abnoruially  distended  "with  blood.  I  searched  for 
microorganisms,  and  found  them  in  abundance  upon  the  free  surface  of 
the  intestine,  in  the  mucous  accumulations  there,  and  also  in  the  mouths 
of  the  glands  of  Lieberklihn.  Both  rod-shaped  and  small  round  bac- 
teria Avere  found.  I  attach  no  especial  importance  to  finding  bacteria 
upon  the  surfice  of  the  intestine.  The  general  result  of  the  examina- 
tion is  to  confirm  the  view  that  cholera  infantum  is  characterized  by  an 
acute  intestinal  inflammation." 

Nature. — Cholera  infantum  appears  from  its  symptoms  and  lesions 
to  be  the  most  severe  form  of  intestinal  catarrh  to  which  infants  are 
liable.  The  alvine  discharges,  to  "which  the  rapid  prostration  is  largely 
due,  probably  consist  in  part  of  intestinal  secretions  and  in  part  of  serum 
Avhich  has  transuded  from  the  capillaries  of  the  intestines.  That  the 
intestinal  mucous  membrane  sometimes  presents  a  pale  appearance  at 
the  autopsy  of  an  infant  Avho,  previously  Avell,  has  died  of  cholera  in- 
fantum after  a  sickness  of  twenty-four  or  forty-eight  hours,  is  perhaps 
due  to  the  great  amount  of  liquid  secretion  and  transudation  in  Avhich 
the  inflamed  surface  is  bathed.  Moreover,  it  is,  1  believe,  a  recognized 
fact  that  the  h3^perfemia  of  an  acutely  inflamed  surface  Avhen  of  short 
duration  frequently  disappears  in  the  cadaver,  as  that  of  scarlet  fever 
and  erysipelas.  The  early  hyperplasia  of  the  solitary  and  mesenteric 
glands,  and  the  hyperemia  and  thickening  of  the  surface  of  the  ileum 
and  colon  in  those  Avho  have  survived  a  few  day,  indicate  the  inflamma- 
tory character  of  the  malady. 

The  opinion  has  been  expressed  by  certain  observers  that  cholera 
infantum  is  identical  with  thermic  fever  or  sunstroke.  There  is  indeed 
a  resemblance  to  thermic  fever  as  regards  certain  important  symptoms. 
In  cholera  infantum  the  temperature  is  from  105°  to  108°  ;  in  sunstroke 
it  is  also  very  high,  often  running  above  108°.  Great  heat  of  head, 
contracted  pupils,  thin  fecal  evacuations,  embarrassed  respiration, 
scanty  urine,  and  cerebral  symptoms  are  common  toward  the  close  of 
cholera  infantum,  and  they  are  the  prominent  symptoms  in  sunstroke. 
Nevertheless,  I  cannot  accept  the  theory  which  regards  these  maladies 
as  identical,  and  which  removes  cholera  infantum  from  the  list  of  intes- 
tinal diseases.  In  cholera  infantum  the  gastro-intestinal  symptoms 
always  take  the  precedence,  and  are,  except  in  advanced  cases,  always 
more  prominent  than  other  symptoms.  It  does  not  commence  as  by  a 
stroke  like  couj)  de  soldi,  but  it  comes  on  more  gradually,  though 
rapidl}^,  and  it  often  supervenes  upon  a  diarrhoea  or  some  error  of  diet. 
In  the  commencement  of  cholera  infantum  the  infant  is  usually  not 
drowsy,  and  is  often  wide  awake  and  restless  from  the  thirst.  Contrast 
this  with  the  alarming  stupor  of  sunstroke.  Sunstroke  only  occurs 
during  tlie  hours  of  excessive  bent,  but  cholera  infantum  may  occur  at 
any  hour  or  in  any  day  during  the  hot  Aveathcr,  provided  that  there  be 
sufficient  dietetic  cause.  Again,  intestinal  inflammation  is  not  common 
in  sunstroke,  while  it  is  the  common,  or,  as  I  believe,  the  essential 
lesion  of  cholera  infantum.  These  facts  show,  in  my  opinion,  that  the 
two  maladies  are  essentially  and  entirely  distinct.  Nevertheless,  cases 
of  apparent  sunstroke  sometimes  occur  in  the  infant,  jind  if  tlic  ])owels 


TREATMENT.  739 

are  at  the  same  time  relaxed  the  disease  may  be  regarded  as  cholera 
infantum,  and  if  fatal  is  usually  reported  as  such  to  the  health  authori- 
ties. Cases  of  this  kind  I  have  occasionally  observed  or  they  have  been 
reported  to  me,  although  they  are  not  common. 

With  the  exception  of  the  organs  of  digestion  no  uniform  lesions  are 
observed  in  any  of  the  viscera  in  cholera  infimtum,  except  such  as  are 
due  to  change  in  the  quantity  and  fluidity  of  the  blood  and  its  circula- 
tion. Writers  describe  an  annemic  appearance  of  the  thoracic  and 
abdominal  viscera,  and  occasionally  passive  congestion  of  the  cerebral 
vessels.  The  cerebral  symptoms  usually  present  toward  the  close  of  life 
in  unfavorable  cases  of  cholera  infantum  are  often  due  to  spurious 
hydrocephalus,  which  we  have  described  above ;  but  as  the  urinary 
secretion  is  scanty  or  suppressed,  cerebral  symptoms  may,  in  certain 
cases,  be  due  to  umemia. 

Diagnosis. — This  form  of  the  summer  diarrhoea  is  diagnosticated  by 
the  symptoms,  and  especially  by  the  frequency  and  character  of  the 
stools.  The  stools  have  already  been  described  as  fi-equent,  often  passed 
with  considerable  force,  deficient  in  fecal  matter,  and  thin,  so  as  to  soak 
into  the  diaper  almost  like  urine.  The  vomiting,  thirst,  rapid  sinking, 
and  emaciation  serve  to  distinguish  cholera  infantum  from  other  diar- 
rhfjeal  maladies. 

When  Asiatic  cholera  is  prevalent  the  differential  diagnosis  between 
the  two  is  difficult  if  not  impossible. 

Progxosis. — Cholera  infantum  is  one  of  those  diseases  in  regard  to 
which  physicians  often  injure  their  reputation  by  not  giving  sufficient 
notice  of  the  danger,  or  even  by  expressing  a  favorable  opinion  Avhen 
the  case  soon  after  ends  fatally.  A  favorable  prognosis  should  seldom 
be  expressed  without  qualification.  If  the  urgent  symptoms  be  relieved, 
still  the  disease  may  continue  as  an  ordinary  intestinal  inflammation, 
which  in-  hot  weatlier  is  formidable  and  often  fatal.  If  the  stools 
become  more  consistent  and  less  frecjuent  without  the  occurrence  of 
cerebral  symptoms,  while  the  limbs  are  warm  and  the  pulse  good,  we 
may  confidently  express  the  opinion  that  there  is  no  present  danger. 

The  duration  of  true  cholera  infantum  is  short.  It  either  ends 
fatally,  or  it  begins  soon  to  abate  and  ceases,  or  it  continues,  and  is  not 
to  be  distinguished  in  its  subsequent  course  from  an  attack  of  summer 
diarrh<e:i  beginning  in  the  ordinary  manner. 

Trkatmext  of  IxfaxtiFvE  l)iARRn<?:A. — Obviously,  efficient  preven- 
tive measures  consist  in  the  removal  of  infants  so  far  as  practicable  from 
the  operation  of  the  causes  which  produce  the  disease.  Weaning  just 
before  or  in  the  hot  weather  siiould,  if  possible,  be  avoided,  and  removal 
to  the  country  sliould  be  recommended,  especially  for  tiiose  who  are  de- 
prived of  breast-milk  during  the  age  when  such  nutriment  is  re([uired. 
If  f  )r  any  reason  it  is  necessary  to  employ  artificial  fee<ling  for  infants 
under  the  a^e  of  ten  months,  that  food  should  obviouslv  be  used  wliich 
most  closely  resembles  human  milk  in  digestibility  and  in  nutritive 
properties.  Care  should  be  taken  to  prevent  fermentation  in  the  food 
before  its  use,  since  much  harm  is  done  by  the  employment  of  milk  or 
other  food  in  which  fermentative  changes  have  occurred  and  which 
occur  quickly  in  dietetic  mixtures  in  the  hot  months. 


740  CHOLERA    INFANTUM. 

It  is  also  very  important  that  the  infant  receive  its  food  in  proper 
quantity  and  at  proper  intervals,  for  if  the  mother  or  nurse  in  her 
anxiety  to  have  it  thrive  feed  it  too  often  or  in  too  large  quantity,  the 
surplus  food  ■which  it  cannot  digest  if  not  vomited  undergoes  fermenta- 
tion, and  consequently  becomes  irritating  to  the  gastro-intestinal  sur- 
face. The  physician  should  be  able  to  give  advice  not  only  in  reference 
to  the  frequency  of  feeding,  but  also  in  regard  to  the  quantity  of  food 
Avhich  the  infant  requires  at  each  feeding.  Correct  knowledge  and 
advice  in  this  matter  aid  in  the  prevention  and  cure  of  the  diarrhoeal 
maladies  of  infancy.  The  reader  is  referred  to  the  chapters  relating  to 
the  feeding  of  infants.  Avoidance  of  exposure  to  cold  or  to  sudden 
changes  of  temperature  are  important  preventive  measures,  since  cases 
of  intestinal  catarrh  of  infants  occur  from  this  cause,  though  less  fre- 
quently than  from  errors  in  diet. 

Curative  Treatment. — The  indications  for  treatment  are:  1st.  To 
provide  the  best  possible  food,  ■which  ■will  aflbrd  sufficient  nutriment, 
and  be  easily  digested.  2d.  To  aid  the  digestive  functions  of  the  infant, 
od.  To  employ  such  medicinal  agents  as  can  be  safely  given  to  check 
the  diarrhoea  and  cure  the  intestinal  catarrh.  4th.  To  procure  fresh 
air,  ■which  is  especially  needed  if  tiie  diarrhoea  be  that  of  the  summer 
season. 

The  infant  ■with  this  disease  is  thirsty,  and  is  therefore  likely  to  take 
more  nutriment  in  the  liquid  form  than  it  requires  for  its  sustenance. 
If  nursing,  it  craves  the  breast,  or  if  weaned,  craves  the  bottle,  at  short 
intervals,  to  relieve  the  thirst.  No  more  nutriment  should  be  allowed 
tiian  is  required  for  nutrition,  for  the  reason  stated  above,  and  the  thirst 
may  best  be  relieved  by  a  little  cold  water,  gum-water,  or  barley-water, 
to  Avhicli  a  few  drops  of  brandy  or  "whiskey  are  added.  Infantile  diar- 
rhoea of  the  summer  season,  so  common  and  fatal  in  the  cities,  requires 
m  some  respects  different  treatment  from  that  Avhich  is  appropriate  for 
diarrhoea  occurring  at  other  seasons,  and  due  to  other  causes  than  those 
incident  to  hot  Aveather. 

Since  one  of  the  two  important  fictors  in  producing  the  summer 
diarrhea  is  the  use  of  improper  food,  it  is  obviously  very  important  for 
the  successful  treatment  of  this  disease  that  the  food  should  be  of  the 
right  kind,  properly  prepared,  and  given  in  proper  quantity.  I  need 
not  repeat  that  for  infants  under  the  age  of  one  year  no  food  is  so  suit- 
able as  breast-milk,  and  one  affected  with  the  diarrhoea  and  remaining 
in  the  city  should,  if  possible,  at  least  if  under  the  age  often  months,  be 
provided  with  breast-milk.  It  can  be  more  satisfactorily  treated  and 
the  chances  of  its  recovery  are  much  greater  if  it  be  nourished  with 
haman  milk  than  by  any  other  kind  of  diet.  If,  however,  the  mother's 
milk  fail  or  become  unsuitable  from  ill-health  or  pregnancy,  and  on 
account  of  family  circumstances  a  wet-nurse  cannot  be  procured,  the 
important  and  difficult  duty  devolves  upon  the  physician  of  deciding 
how  the  infant  should  be  fed.  The  reader  is  referred  to  Chapter  VIII. 
Part  I.,  for  facts  relating  to  the  feeding  of  infants. 

But  since  one  of  the  two  important  factors  in  producing  the  summer 
diarrhoea  of  infants  is  foul  air,  it  is  obvious  that  measures  should  be 
employed  to  render  the  atmosphere  in  -which  the  infant  lives  as  free  as 


CURATIVE    TREATMEXT.  741 

possible  from  noxious  effluvna.  Cleanliness  of  the  person,  of  the  bed- 
dinof,  and  of  the  house  in  -which  the  patient  resides,  the  prompt  removal 
of  all  refuse  animal  or  vegetable  matter,  whether  within  or  around  the 
premises,  and  allowing  the  infant  to  remain  a  considerable  part  of  the 
day  in  shaded  localities  where  the  airMs  pure,  as  in  the  parks  or  suburbs 
of  the  city,  are  important  measures.  In  New  York  great  benefit  has 
resulted  from  the  floating  hospital  which  every  second  day  during  the 
heated  term  carries  a  thousand  sick  children  from  the  stifling  air  of  the 
tenement  houses  down  the  bay  and  out  to  the  fresh  air  of  the  ocean. 

But  it  is  difficult  to  obtain  an  atmosphere  that  is  entirely  pure  in  a 
large  city  with  its  many  sources  of  insalubrity;  and  all  physicians  of 
experience  agree  in  the  propriety  of  sending  infants  aftected  with  the 
summer  diarrhoea  to  localities  in  the  country  which  are  free  from  malaria 
and  sparsely  inhabited,  in  order  that  they  may  obtain  the  benefits  of 
purer  air.  Many  are  the  instances  each  summer  in  New  York  City  of 
infants  removed  to  the  country  with  intestinal  inflammation,  with  fea- 
tures iiaggard  and  shrunken,  with  limbs  shrivelled  and  the  skin. lying  in 
folds,  too  weak  to  raise,  or  at  least  hold,  their  heads  from  the  pillow, 
vomiting  nearly  all  the  nutriment  taken,  with  stools  frequent  and  thin, 
resulting  in  great  part  from  molecular  disintegration  of  the  tissues — 
presenting,  indeed,  an  appearance  seldom  observed  in  any  other  disease 
except  in  the  last  stages  of  phthisis — and  returning  in  late  autumn  with 
the  cheerfulness,  vigor,  and  rotundity  of  health.  The  localities  usually 
prefei'red  by  the  physicans  of  this  city  are  th«  elevated  portions  of  New 
Jersey  and  Northern  Pennsylvania,  the  Highlands  of  the  Hudson,  the 
central  and  northern  parts  of  New  York  State,  and  Northern  New 
England.  Taken  to  a  salubrious  locality  and  properly  fed,  the  infant 
soon  begins  to  improve  if  the  disease  be  still  recent,  unless  it  be  excep- 
tionally severe.  If  the  disease  have  continued  several  weeks  at  the  time 
of  the  removal,  little  benefit  may  be  observed  from  the  country  residence 
until  two  or  more  weeks  have  elapsed. 

An  inf  mt  Aveakened  and  wasted  by  the  summer  diarrhoea,  removed  to 
a  cool  locality  in  tlie  country,  should  be  warmly  dressed  and  kept  indoor 
when  the  heavy  night  dew  is  falling.  Patients  sometimes  become  worse 
from  injudicious  exposure  of  this  kind,  the  intestinal  catarrh  from  which 
they  are  suft'ering  being  aggravated  by  taking  cold,  and  perhaps  ren- 
dered dysenteric. 

Sometimes  parents,  not  noticing  the  immediate  improvement  which 
they  have  been  led  to  expect,  return  to  the  city  without  giving  the 
country  fair  trial,  and  the  life  of  the  infant  is  then,  as  a  rule,  sacri- 
ficed. Returned  to  the  foul  air  of  the  city  while  the  weather  is  still 
warm,  it  sinks  rapidly  from  an  aggravation  of  the  malady.  Occasion- 
ally, the  change  from  one  rural  locality  to  another,  like  the  change  from 
one  wet  nurse  to  another,  has  a  salutary  effect.  The  infant,  although 
it  has  recovered,  shouM  not  be  brought  back  while  the  weather  is  still 
warm.  One  attack  of  the  disease  does  not  diminish,  but  increases,  the 
liability  to  a  second  seizure. 

Medicinal  Treatment.  The  diarrhoea  of  infancy  requires,  to  some 
extent,  different  treatment  in  its  early  and  later  stages.  We  have  seen 
that    acids,   especially   the   lactic   and   butyric,   the    results    of    faulty 


74:2         INTESTINAL  CATARRH  OF  INFANCY, 

digestion,  are  often  produced,  causing  acid  stools.  In  a  few  days  the 
intiainmatory  irritation  of  the  mucous  follicles  causes  such  an  exag- 
gerated secretion  of  alkaline  mucus  that  the  acid  is  nearly  or  quite 
neutralized.  In  the  commencement  of  the  attack  these  acid  and  irri- 
tating products  should  be  as  quickly  as  possible  neutralized,  Avhile 
we  endeavor  to  prevent  their  production  by  imj)roving  the  diet  and 
assisting  the  digestion.  In  the  second  stage,  when  the  fecal  matter  is 
less  acid  and  irritating  from  the  large  admixture  of  mucus,  medicines 
are  required  to  improve  digestion  and  check  the  diarrhoea,  while  the 
indication  for  antacids  is  less  urgent.  Therefore  it  is  convenient  to 
consider  separately  the  treatment  which  is})roper  in  the  commencement 
or  first  stage,  and  that  which  is  required  in  the  subsequent  course  of  the 
disease. 

First  stage,  or  during  the  first  three  or  four  days,  perhaps  the  first 
week.  Occasionally,  it  is  proper  to  commence  the  treatment  by  the 
employment  of  some  gentle  purgative,  especially  when  the  disease  begins 
abruptly  after  the  use  of  indigestible  and  irritating  food.  A  single  dose 
of  castor  oil  or  syrup  of  rhubarb,  or  the  two  mixed,  will  remove  the 
irritating  substance,  and  afterward  oj)iates  or  the  remedies  designed  to 
control  the  disease  can  be  more  successfully  employed.  Ordinarily,  such 
preliminary  treatment  is  not  required.  Diarrh(jea  has  generally  con- 
tinued several  days  when  the  physician  is  summoned,  and  no  irritating 
substance  remains  save  the  acid  which  is  so  abundantly  generated  in 
the  intestines  in  this  disease,  and  which  we  have  the  means  of  removing 
without  j)urgation. 

The  same  general  plan  of  medicinal  treatment  is  appropriate  for  the 
summer  diarrhoea  of  infants  as  for  diarrhoea  from  other  causes ;  but  the 
acid  fermentation  present  in  greater  degree  in  the  former  than  in  the 
latter,  indicates  the  greater  need  of  antacids,  which  should  be  employed 
in  most  of  the  mixtures  used  in  the  first  stage  as  lonjT  as  the  stools  have 
a  decidedly  acid  reaction. 

Those  who  accept  the  theory  that  infanti'e  diarrhcea  of  the  summer 
season  is  produced  by  microorganisms  which  lodge  on  the  gastro- 
intestinal surface  and  produce  diarrha?a  by  their  irritating  effect,  are 
naturally  led  to  employ  antiseptic  remedies.  Guaita  administered  for 
this  purpose  sodium  bcnzoate.  One  drachm  or  a  drachm  and  a  half 
dissolved  in  three  ounces  of  water  were  administered  in  twenty-four 
hours  Avith,  it  is  stated,  good  results.^  I  have  no  experience  in  the  use 
of  antiseptic  remedies  in  any  form  of  infimtile  diarrha3a. 

If  by  the  appearance  of  the  stools  or  the  substance  ejected  from  the 
stnuiach,  or  by  the  usual  test  of  litmus-paper,  the  presence  of  an  acid  in 
an  irritating  quantity  be  ascertained  or  sus])ccted,  lime-water  or  sodium 
bicarbonate  may  be  added  to  the  food.  The  creta  pr^eparata  of  the 
Pharmacopoeia  administered  every  two  hours,  or,  Avhich  is  more  con- 
venient, the  mistura  cretre,  is  a  useful  antacid  for  such  a  case.  The 
chalk  should  be  finely  triturated.  By  alkalies  ahme,  aided  by  the  judi- 
cious use  of  stimulants,  the  disease  is  sometimes  arrested,  but,  unless 
circumstances  ai'e  favorable  and  the  case  be  mild,  other  remedies  are 
required. 

»  New  York  Medical  Record,  May  31,  1884. 


CURATIVE    TREATMENT.  743 

Opium  has  long  been  used,  and  it  retains  its  place  as  one  of  the  im- 
portant remedies  in  infantile  diarrhoea.  For  the  treatment  of  a  young 
infant  paregoric  is  a  convenient  opiate  preparation.  For  the  age  of 
one  or  t\yo  months  the  dose  is  from  three  to  five  drops ;  for  the  age  of 
six  months,  twelve  drops,  repeated  eVery  three  hours  or  at  longer  in- 
tervals according  to  the  state  of  the  patient.  After  the  age  of  six 
months  the  stronger  preparations  of  opium  are  more  commonly  used. 
The  tinctura  opii  deodorata  or  vSquibbs  liquor  opii  compositus  may  be 
given  in  doses  of  one  drop  at  the  age  of  one  year.  Dover's  powder  in 
doses  of  three-fourtlis  of  a  grain,  or  the  pulvis  cret^e  comp.  cum  opio  in 
three-grain  doses  every  third  hour,  may  be  given  to  an  infant  of  one  year. 

Opium  is,  however,  in  general  best  given  in  mixtures  which  Avill  be 
mentioned  hereafter.  •  It  quiets  the  action  of  the  intestines  and  dimin- 
ishes the  nuuiber  of  the  evacuations.  It  is  contraindicated  or  should  be 
used  with  caution  if  cerebral  symptoms  are  present.  Sometimes  in  the 
commencement  of  the  disease,  when  it  begins  abruptly  from  some  error 
in  diet,  with  high  temperature,  drowsiness,  twitching  of  the  limbs — 
symptoms  which  threaten  eclampsia — opiates  should  be  given  cautiously 
before  free  evacuations  occur  from  the  bowels  and  the  offending  sub- 
stance is  expelled.  Under  such  cii'cumstances  a  few  doses  of  the  bromide 
of  potassium  are  preferable.  In  the  advanced  stage  of  the  disease  also, 
when  symptoms  of  spurious  hydrocephalus  occur,  opium  should  be  with- 
held or  cautiously  administered,  since  it  may  tend  to  increase  the  fatal 
stupor  in  which  severe  cases  are  liable  to  terminate;  but,  except  in  such 
cases,  opium  is  a  most  useful  remedy. 

The  vegetable  astringents,  although  they  have  been  largely  employed 
in  the  treatment  of  the  various  forms  of  infantile  diarrhoea,  are  much 
less  frequently  prescribed  than  formerly.  As  a  substitute  for  them  the 
subnitrate  of  bismuth  has  come  into  use,  and  in  much  larger  doses  than 
were  fn-merly  employed.  While  it  aids  in  checking  the  diarrhoea,  it  is 
an  efficient  antiemetic  and  antiseptic.  It  should  be  prescribed  in.ten  or 
twelve  grains  fn*  an  infant  of  twelve  months;  larger  doses  produce  no 
ill  eHTect,  for  its  action  is  almost  entirely  local  and  soothing  to  the  in- 
flamed surface  with  which  it  comes  in  contact.  It  undergoes  a  chemical 
change  in  the  stomach  and  intestines,  becoming  black,  being  converted 
into  the  bismuth  sulphide,  and  it  causes  dark  stools.  Rarely  it  pro- 
duces in  the  infant  the  well-known  garlicky  odor,  like  that  occasionally 
observed  in  adidt  patients,  and  which  is  supposed  to  be  due  to  tellurium 
accidentally  associated  with  the  bismuth  in  its  natural  state.  For  those 
cases  in  which  the  symptoms  are  chiefly  due  to  colitis,  and  the  stools 
contain  blood  with  a  large  proportion  of  mucus,  it  has  been  customary 
to  prescribe  laudanum  or  some  other  form  of  opium  with  castor  oil.  I 
prefer,  however,  the  bismuth  and  oi)ium  for  such  crises  as  are  more  de- 
cidedly dysenteric,  as  well  as  for  cases  of  the  usual  form  of  intestinal 
catarrh. 

The  following  are  convenient  and  useful  formulae  for  a  child  of  one  year : 

li. — Ti not.  opii  dendnrat Tllxvj. 

IJisiiuUh.  subnitrat.      ......      ^ij- 

Svrupi t.^ij 

Misiurre  crotaj fixiv. — Misce. 

Shuko  thoroughly  uiid  give  one  teaspoonful  every  two  to  four  nouri. 


744  INTESTINAL    CATARRH    OF    INFANCY. 

R. — Tinct.  opii  deodorat TTLxvj. 

Bismuth,  subnitral.      .         .         .         .         .         •      S'j- 

Synipi t  5ss 

Aq.  cinnamomi f'^'us. — Misce. 

Shake  bottle;  give  one  teaspoonfiil  every  two  to  four  hours. 

Be  — Bismuth  subtiitrat ^ij 

Pulv.  cret.  comp.  c.  opio     .....      ^.-s — Misce. 
Divid  in  chart  No.  x.     Dose,  one  powder  every  three  hours. 

R. — Bismuth,  subnitrat ^ij. 

Pulv.  ipecac   comp.      ......     gr.  i.x. — Misce. 

Divid  in  chart  No.  xii.     Dose,  one  powder  every  three  hours. 

Cholera  infantum  requires  similar  treatment  to  that  which  is  proper 
for  the  ordinary  form  of  infantile  diarrhoea,  but  there  is  no  disease, 
unless  it  is  pseudo-membranous  croup,  in  whicli  early  and  appropriate 
treatment  is  more  urgently  required,  since  the  tendency  is  to  rapid  sink- 
ing and  death.  As  early  as  possible,  therefore,  proper  instructions 
should  be  given  in  regard  to  the  feeding,  and  for  an  infant  between  the 
ages  of  eight  and  twelve  months  either  one  of  the  above  prescriptions 
should  be  given  or  the  following  : 

R  — Tinct.  opii  deodorat.    ......     TTtxvj. 

Spts.  ammon.  aromat.  .....     f^j. 

Bismuth,  subnitiat.     .         .         .         .         .         •      S'j- 
Mucii.  acacire  vel  syrupi        .....      fi'^S. 

Mistura?  cretiB      .......     f^iss — Misce. 

Shake  bottle.     Give  one  teaspoonful  every  two  or  three  hour.s. 

An  infant  of  six  months  can  take  one-half  the  dose,  and  one  of  three 
or  four  months  one-third  or  one-fourth  the  dose,  of  either  of  the  above 
mixtures. 

If  cerebral  symptoms  appear,  as  rolling  the  head,  drowsiness,  etc.,  I 
usually  write  the  prescription  without  the  opiate;  and  with  this  omission 
it  may  be  given  more  frequently  if  the  case  require  it,  while  the  opiate 
prescribed  alone  or  with  bromide  of  potassium  is  given  guardedly  and  at 
longer  intervals.  Injury  to  the  patient  from  the  use  of  the  opiate  can 
only  occur  through  carelessness  in  not  giving  pro])er  attention  to  his 
condition.  It  is  chiefly  in  advanced  cases,  when  the  vital  powers  are 
beginning  to  fail,  when  the  innervation  is  deficient,  and  cerebral  circula- 
tion sluggish,  that  the  use  of  opiates  may  involve  danger.  Explicit  and 
positive  directions  should  be  given  to  omit  the  opiate  or  to  give  it  less 
frequently  whenever  the  evacuations  arc  checked  wholly  or  partially  and 
signs  of  stupor  appear. 

Second  Stage.  Infantile  diarrhoea  in  a  large  proportion  of  cases 
begins  in  such  a  gradual  way  that  the  treatment  which  we  arc  about  to 
recommend  is  proper  in  many  instances  at  the  first  visit  of  the  physi- 
cian, who  is  frequently  not  summoned  until  the  attack  has  continued 
one  or  two  weeks.  The  alkaline  treatment  recommended  above  f  >r  the 
diarrhoea  in  its  commencement  does  not  aid  digestion  sufficiently  to 
justify  its  continuance  as  the  main  remedy  after  the  first  few  days.  In 
a  large  number  of  instances,  however,  one  of  the  above  alkaline  mix- 
tures may  be  given  with  advantage  midway  between  the  nursings  or 


CURATIVE    TREATMENT.  745 

■feedings,  while  those  remedies,  presently  to  be  mentioned,  which  facili- 
tate  digestion  and  assimilation  are  given  at  the  time  of  the  reception 
of  food. 

S^me  physicians  of  large  experience,  as  Henoch,  of  Berlin,  recom- 
mend small  doses  of  calomel,  as  the  twelfth  or  twentieth  of  a  grain, 
three  or  four  times  daily  for  infants  with  faulty  digestion  and  diarrhfBa. 
To  me,  this  seems  an  uncertain  remedy,  without  sufficient  indications 
for  its  use,  and  I  have  therefore  no  experience  with  it.  The  following 
are  formulae  which  I  employ  in  my  own  practice,  which  have  been  em- 
ployed with  apparent  good  results  in  the  institutions  in  New  York  in 
these  frequent  cases  in  which  diarrhoea  is  associated  with  indigestion : 

R. — Acid,  miiriat.  dilut TTtxvj. 

Pe^isiniesticcharat.  (Hawley's  or  other  good  pepsin)  ^j. 
Bismuth,  subnitrat.       .         .         .         ,         .         .      ^ij. 

Syiupi ^3U- 

Aqute   .........     fjxiv. — Misce. 

Shake  botiL'  ;  trive  one  teaspoonful  bef  )re  each  feeding  or  nursing  to  an  infant 
of  one  year  ;  half  a  lea^poonfiil  to  une  of  six  months. 

R. — Tinct.  opii  deodorat Ttl^^j- 

Pe|  siiiic  saccharat.        ......  5J. 

Bi-mnth.  subniirat 3  ij. 

Sytupi t^ij. 

Aqiue   .........  fjxiv. — Misce. 

Shakp  b'ttle  :  cive  one  teaspoonful  every  three  hours  to  a  child  of  one  year; 
nail'  a  leasjiocnful  to  one  of  six  months. 

R. — Pen^inaj  saocharat.        ......      ^j-'j- 

Bisiniiih.  i-ubnitrat.      ......      31) — Misce. 

Divid  in  chart  No.  xii.     One  powder  every  three  hours  to  a  child  of  one  year. 

In  occasional  cases  in  which  the  stomach  is  very  irritable,  so  that 
medicines  given  by  the  mouth  are  in  great  part  rejected,  our  reliance 
must  be  largely  on  rectal  medication,  and  especially  on  clysters  contain- 
ing an  opiate.  Laudanum  may  be  given  in  this  manner  with  marked 
benefit.  It  may  be  given  mixed  with  a  little  starcli-water,  and  the  best 
instrument  for  administering  it  is  a  small  glass  or  gutta  percha  syringe, 
tlic  nurse  retaining  the  enema  for  a  time  by  means  of  a  compress. 
Beck,  in  liis  Infant  Therapeutics,  advises  to  give  by  the  clyster  twice  as 
much  of  the  opiate  as  would  be  required  by  the  mouth.  A  somewhat 
larirer  proportion  may,  however,  be  safely  employed.  The  following 
foimula  for  a  clyster  has  given  me  more  satisfaction  than  any  other 
medicated  enema  which  I  have  employed : 

R. — Arirent.  nitrat.       .         .         .         .         .         .         .     pr.  iv. 

Hisinuth.  subnitrat.       .         .         .         .         .         .     g-s. 

M'icilag.  acacise  1  ..  ,-■■      ai;,,../^ 

.  "  V  ......     aa  t  z\]. — .Misce. 

Aquae  J  '^  •' 

One-quarter  to  one-half  of  this  should  be  given  at  a  time,  with  the 
addition  of  as  much  laudanum  as  is  thougbt  projjcr ;  ami  it  should  be 
reta-ned  by  tlie  compress.  It  is  especially  useful  when  fi-oin  the  largo 
amount  of  mucus  or  mucus  tinged  with  blood  it  is  probable  tliat  the 
descending  colon  is  chiefly  involved. 


7-iG        INTESTINAL  CATARRH  OF  INFANCY. 

Alcoholic  Stimulants  are  required  almost  from  the  commencement  of 
the  disease,  and  they  shoukl  be  employed  in  all  protracted  cases. 
Whiskey  or  brandy  is  the  best  of  these  stimulants,  and  it  should  be 
given  in  small  dosesi  at  intervals  of  two  hours,  I  usually  order  three  or 
four  drops  for  an  infant  of  one  month,  and  an  additional  drop  or  two 
drops  for  each  additional  mouth.  The  stimulant  is  not  only  useful  in 
sustaining  the  vital  powers,  but  it  also  aids  in  relieving  the  irritability 
of  the  stomach  and  in  preventing  hypostasis  in  depending  portions  of  the 
lung  and  brain,  wliich,  as  Ave  have  seen,  is  so  frequent  in  advanced  cases. 

The  vomiting  which  is  so  common  a  symptom  in  many  cases  greatly 
increases  the  prostration,  and  should  be  immediately  relieved  if  possible. 
The  following  formulae  will  be  found  useful  for  it : 

R. — Bismuth,  subnitrat Jij. 

Spis.  ariimon.  arumat.  ......     IS'^s-^j- 

^y'-^\''\ ruif5j.-Misco. 

Aqiiaj    J  ^•' 

Shake  bottle.  Dose,  one  teaspounful  half-hourly  or  hourly  if  required,  made  cold 
by  a  piece  of  ice. 

R. — Acid,  carbolic ptt.  ij. 

Liquor,  calcis f^ij — Misce. 

Do?e,  one  teaspoonful,  with  a  teaspoonful  of  milk  (breast-milk  if  the  baby  nurse), 
to  be  repeated  according  to  the  nausea. 

Lime-water  with  an  equal  quantity  of  milk  often  relieves  the  nausea 
when  it  is  due  to  acids  in  the  stomach,  but  it  is  rendered  more  effectual 
in  certain  cases  by  the  addition  of  carbolic  acid,  which  tends  to  check 
any  fermentative  process.  A  minute  dose  of  tincture  of  ipecacuanha, 
as  one-eighth  of  a  drop  in  a  teaspoonful  of  ice-water,  frequently  repeated, 
has  also  been  employed  with  alleged  benefit. 

Of  these  various  antiemetics,  my  preference  is  for  the  bismuth,  in  large 
doses,  Avith  the  aromatic  spirits  of  ammonia,  properly  diluted,  that  the 
ammonia  do  not  irritate  the  stomach.  Nevertheless,  in  certain  patients 
the  nausea  is  very  obstinate,  and  all  these  remedies  fail.  In  suth  cases 
absolute  quiet  of  the  infant  on  its  back,  the  administration  of  but  little 
nutriment  at  a  time,  mustard  over  the  epigastrium,  and  the  use  of  an 
occasional  small  piece  of  ice  or  the  use  of  carbonic  acid  water  with  ice 
in  it,  may  relieve  this  symptom. 

In  protracted  cases,  when  the  vital  powers  begin  to  fail,  as  indicated 
by  pallor,  more  or  less  emaciation,  and  loss  of  strength,  the  folloAving  is 
the  best  tonic  mixture  with  which  I  am  acquainted.  It  aids  in  restrain- 
ing the  diarrhoea,  Avhile  it  increases  the  appetite  and  strength.  It  sliould 
not  be  prescribed  until  the  inflammation  has  assumed  a  subacute  or 
chronic  character  : 

R. — Tinct.  colnmbae fo'ij- 

Liq.  ferri  nitratis IfTixxvij. 

Syriipi fgiij.— Misce, 

Dose,  one  teaspoonful  every  three  or  four  hours  to  an  infant  of  one  year. 

External  Treatment. — Some  writers  recommend  depletion  by 
leeching  in  intestinal  inflammation,  when  the  infant  is  rol)ust  and  of 
full  habit,  and  the  disease  commences  suddenly  with  decided  febrile 


ENTERITIS     AXD    COLITIS    IX    CHILDHOOD.  747 

reaction.  Such  cases  are  oftenest  seen  with  us  in  the  "winter  season, 
and  even  these  are  ordinarily  best  treated  without  loss  of  blood.  Sina- 
pisms and  poultices  usually  are  sufficient  as  local  measures.  In  these 
cases,  also,  the  warm  mustard  foot-bath  should  be  employed,  and  repeated 
if  there  be  restlessness  or  cerebral  symptoms. 

In  all  forms  of  intestinal  inflammation  in  infancy  and  in  all  its  stages 
mild  counter-irritation  over  the  abdomen  is  often  useful,  but  vesication, 
by  increasing  the  restlessness  of  the  infant  and  reducing  its  strength, 
without  materially  modifying  the  severity  or  duration  of  the  disease, 
does  more  harm  than  good.  It  is  not  to  be  thought  of  as  a  remedial 
measure.  I  have  known  a  troublesome  sore  continuing  till  death,  and 
probably  hastening  this  result,  to  occur  from  this  treatment.  Poultices 
or  fomentations  over  the  abdomen  are  sometimes  beneficial,  especially 
those  of  a  mildly  irritating  nature.  A  poultice  of  powdered  cloves,  cin- 
namon, and  ginger,  or  of  linseed  meal  to  which  a  little  mustard  is  added, 
may  be  employed,  or  a  linseed  poultice  spread  thin,  under  which  a  single 
layer  of  muslin  is  placed,  saturated  witii  camphorated  oil  or  tincture  of 
camphor,  and  over  both  oil  silk.  In  the  entero-colitis  of  infants,  occur- 
ring in  the  cool  months,  and  due  to  exposure  to  cold,  this  treatment  is 
especially  useful.  In  the  epidemic  entero-colitis  of  the  summer  months, 
which  may  be  aggravated  by  heat,  treatment  by  poultices  may  be  inju- 
dicious, but  in  such  cases  it  is  proper  to  produce  moderate  redness  over 
the  abdomeu  by  temporary  applications. 


CHAPTER   IX. 

ENTERITIS  AND  COLITIS  IN  CHILDHOOD. 

Intestinal  inflammation  in  childhood  differs  materially  from  the 
form  or  type  which  it  commonly  presents  in  infancy.  Its  causes,  symp- 
toms, and  extent  vary  in  important  particulars  in  the  two  periods.  In 
childhood  there  is  not  ordinarily  such  extensive  inflammation  of  the 
mucous  membrane  of  the  intestines  as  we  have  seen  is  present  in  the 
majority  of  cases  in  infancy,  and  it  may,  therefore,  bo  properly  ti-eated 
as  two  diseases,  according  to  the  seat  of  the  morbid  process,  namely, 
enteritis  and  colitis.  Both  these  aflections  in  the  child  reseiiiljle  so 
closely  the  form  which  they  exhibit  in  adult  life,  that  no  extended 
description  is  needed  in  this  connection. 

Causes. — A  main  cause  is  sudden  reductions  of  temperature  by 
exposure  to  cold,  or  to  currents  of  air,  which  checks  pers|)iration,  and 
causes  determination  of  blood  from  the  surface  to  the  viscera.  These 
inflammations  are  also  caused  sometiiues  bv  irritating  substances  in  the 
intestines.  I  have  known  f(!cal  accumulations  as  well  as  worms  to 
produce  severe  dysentery  iu  the  child,  accuuij)anied  by  the  characteristic 


7-i8  ENTERITIS    AND    COLITIS    IN    CHILDHOOD. 

t>enesmus  and  muco-sanguineous  stools,  and  ceasing  as  soon  as  the  oiFend- 
ing  substances  "were  expelled.  The  use  of  unripe  or  stale  vegetables,  if 
there  be  a  strong  predisposition  to  mucous  inflammation,  may  be  a  suf- 
ficient cause,  and  some  of  the  most  dangerous  cases  are  due  to  the  accu- 
mulation in  the  intestines  of  seeds  and  the  parenchyma  of  fruits.  But 
the  most  common  cause  is  that  mentioned,  namely,  sudden  exposure  to 
cold  when  the  body  is  heated,  a  danger  to  -which  children  are  especially 
liable,  on  account  of  the  easy  disturbance  of  the  circulatory  system  in 
them,  and  their  heedless  exposure  of  themselves,  unless  incessantly 
•watched.  Enteritis  and  colitis  are  also  frequently  secondary  diseases 
occurring  in  chihlhood  as  complications  or  sequekie  of  the  eruptive 
fevers,  especially  measles. 

Symptoms. — The  alvine  discharges  in  enteritis  and  colitis  in  child- 
hood are  such  as  occur  in  these  diseases  at  a  more  advanced  age.  In 
enteritis  they  are  thin  and  of  the  natural  color,  or  occasionally  green ; 
in  colitis  they  are  more  consistent  than  in  enteritis,  and  are  largely 
muco-sanguineous.  Sometimes  in  enteritis,  if  the  inflammation  be  not 
intense,  the  diarrhoea  is  slow  in  appearing,  or  it  may  be  slight,  so  as 
not  to  attract  special  attention.  The  disease  may  tlien  resemble  remit- 
tent fever,  for  which  it  is  at  times  mistaken.  The  upper  part  of  the 
small  intestines  is  less  frequently  affected  than  the  lower.  If  there  be 
duodenitis,  the  flow  of  bile  is  occasionally  impeded  from  tumefaction  of 
the  mouth  of  the  common  bile-duct,  and  the  icteric  hue  appears.  In 
both  enteritis  and  colitis  there  is  abdominal  tenderness,  with  more  or 
less  constant  pain  if  the  disease  be  severe,  and  in  colitis,  tormina  and 
tenesmus.  The  pulse  is  accelerated,  the  heat  of  surface  augmented,  the 
face  flushed,  and,  except  in  mild  cases,  expressive  of  pain.  In  many 
children  at  the  commencement  of  the  inflammation  the  nervous  system 
is  profoundly  aftected,  as  indicated  by  headache,  stupor,  twitching  of 
the  limbs,  and  sometimes  by  convulsions.  The  chief  danger  at  the  com- 
mencement of  the  disease  is,  indeed,  from  this  source.  Sometimes  irri- 
tability of  the  stomach  occurs,  and  the  food  is  rejected,  though  much 
less  frequently  than  in  the  intestinal  inflammation  of  infancy.  Anorexia 
and  tliirst  are  common  symptoms.  If  the  inflammation  continue,  there 
is  soon  perceptible  emaciation,  with  loss  of  strength.  The  eyes  become 
hollow,  the  face  pallid,  and  the  surface  cool.  Death  may  occur  at  an 
early  period,  the  vital  powers  succumbing  from  the  intensity  of  the  in- 
flammation. In  other  cases,  the  acute  disease  ends  in  a  subacute  or 
chronic  inflammation  ;  the  patient  becomes  gradually  more  reduced,  till 
he  dies  in  a  state  of  extreme  emaciation,  such  as  we  often  observe  in  the 
entero-colitis  of  infancy ;  or  froni  this  state  he  may  recover  by  degrees, 
though  ])erhaps  Avitli  an  irrital)le  state  of  the  bowels,  which  continues 
for  months.  In  a  majority  of  cases,  however,  enteritis  and  colitis  in 
childhood,  if  properly  treated,  soon  begin  to  yield,  and  th(;y  terminate 
favorably  in  one  or  two  weeks. 

Diagnosis. — It  is  not  difficult  to  determine  the  existence  of  the  in- 
flammation. This  is  indicated  by  the  fever,  abdominal  tenderness,  and 
the  relaxed  state  of  the  bowels.  Whether  the  disease  bo  enteritis  or 
colitis  is  determined  by  the  character  of  the  stools,  the  seat  of  the  tender- 
ness and  the  presence  or  absence  of  tenesmus. 


TREATMEXT.  74:9 

Prognosis. — It  has  been  stated  above  that  enteritis  and  colitis  in 
children  commonly  terminate  favorably.  The  result  depends  not  only 
on  the  extent  and  severity  of  the  inflammation,  but  the  constitution  and 
previous  health.  The  inflammation  is  more  serious  when  secondary 
than  ■when  primary.  Extensive  and  great  tenderness  of  the  abdomen, 
features  pallid,  anxious,  and  expressive  of  suffering,  pulse  frequent  and 
feeble,  should  excite  the  most  serious  apprehensions.  Frequent  vomit- 
ing also  denotes  a  grave  form  of  the  disease.  Stupor,  and  especially 
convulsive  movements,  show  that  the  nervous  centres  are  affected,  and 
should  make  us  guarded  in  the  prognosis.  Improvement  in  the  dis- 
ease, on  -which  to  base  a  favorable  prediction,  is  apparent  in  the  diminu- 
tion of  the  tenderness,  improvement  in  tbe  pulse  and  character  of  the 
stools,  a  more  cheerful  countenance,  and  less  disrelish  of  food. 

Treataiext. — This  should  be  similar  to  that  employed  for  the  adult. 
In  enteritis  at  the  commencement  of  the  disease,  if  there  be  reason  to 
suspect  the  presence  of  any  irritating  substance  in  the  intestines,  and 
ordinarily  in  colitis,  it  is  advisable  to  commence  treatment  by  the  use 
of  some  simple  evacuant,  like  castor  oil.  After  this  our  reliance,  so  far  as 
internal  treatment  is  concerned,  must  be  mainly  on  opiate  and  antiphlo- 
gistic medicines.  One  of  the  best  remedies  of  this  class  is  the  Dover's 
powder,  which  may  be  given  to  a  child  five  years  old  in  doses  of  three 
grains  every  three  hours.  A  corresponding  dose  of  any  of  the  other 
opiates  may  be  given,  but  with  less  sudorific  effect.  In  colitis  the  occa- 
sional administration  of  a  laxative  should  not  be  neglected,  if  the  stools 
be  entirely  or  mainly  muco-sanguineous.  It  should  be  employed  so  as 
to  prevent  accumulation  of  fecal  matters  in  the  colon,  which  would  serve 
as  an  irritant  and  increase  the  inflammation.  The  dose  should  be  small, 
merely  sufficient  to  produce  fecal  evacuation,  and  rej)eated  as  reijuired, 
daily  or  less  frequently.  The  laxatives  commonly  preferred  are  mag- 
nesia, rhubarb,  or  castor  oil.  The  physician  may  prescribe  an  opiate 
mixture  containing  sufficient  of  the  laxative  to  have  the  effect  desired, 
though  ordinarily  it  is  better  to  prescribe  the  two  separately,  so  that 
the  laxative  can  be  given  or  withheld,  according  to  circumstances,  while 
the  opiate  is  continued  moi-e  regularly.  Except  that  there  be  some 
irritating  substance  which  requires  removal,  the  effect  of  laxatives  is  in- 
jurious, instead  of  beneficial.  Most  of  the  formuhis  given  above  in  our 
remarks  relating  to  the  treatment  of  infantile  intestinal  catarrh  arc  like- 
wise useful  for  the  enteritis  and  colitis  of  childhood,  the  quantity  of  the 
opiate,  which  is  the  important  ingredient,  being  increased  according  to 
the  increase  in  the  age.  The  following  prescriptions  may  be  employed 
for  a  child  of  five  years : 

R. — Pnlv.  opii        .         .         .         .         .         .         .         .     pr.  V. 

IJi-muth.  siihnitrat.         ......      jij — >ri>ce. 

Divid  in  pulveres  ^u.  xx.     Give  one  powder  cverv  two  tu  lour  hours. 

R. — Pulv.  ipecac,  comp.         ......      ^j. 

Iii<mtiih.  suhnilrat.         ......      ^^ij. — Misce. 

Divid  in  jiulveres  No.  xxiv.     Give  one  powder  us  above. 

R — Tine,  opii  dendorat.  ......      :5es. 

Bi«niuii).  subniirat.  .         .         .         .         .         •      3'j' 

Aq.  nientli.  piperit., 

Syr.  zinirilicris         .......     Au  3J. — Misce. 

Shake  botlle.     Give  one  teaspoonful  from  two  to  four  huur^*. 


750  CONSTIPATION. 

Tlie  local  treatment  which  is  found  most  useful  consists  in  the  use  of 
emollient  applications  covered  witli  oil-silk,  and  made  sufficiently  irritat- 
ing by  mustard  or  otherwise  to  cause  constant  redness. 

The  diet  should  be  bhind  and  unirritating.  In  the  first  stages  of  the 
inflammation,  rice  or  barley-water,  or  arrowroot  boiled  in  water,  and 
similar  drinks  should  constitute  the  main  diet.  When  the  active  in- 
flammation has  abated,  and  at  any  period  of  the  disease  if  there  be  a 
tendency  to  prostration,  more  nourishing  food  should  be  given.  INIilk 
and  animal  broths  may  then  be  allowed.  In  cases  which  arc  protracted, 
or  attended  with  symptoms  of  exhaustion,  alcoholic  stimulants  are  re- 
qniired. 


CHAPTEE     X. 

CONSTIPATION 

TiTE  gastro-intestinal  portion  of  the  digestive  apparatus  has  a  double 
function.  First,  it  receives  and  retains  the  food  during  the  i)rocess  of 
digestion  ;  it  furnishes  the  most  important  of  the  liquids  by  which  diges- 
tion is  effected,  and  it  absorbs  those  products  of  digestion  which  are  re- 
quired for  the  nutrition  of  the  body,  while  it  serves  as  a  barrier  against 
the  admission  of  refuse  matter.  Secondly,  it  has  an  excretory  function, 
so  that  a  large  part  of  the  waste  and  noxious  products  of  the  system  are 
eliminated  from  its  surface.  Having,  therefore,  a  relation  so  close  and 
fundamental  to  the  general  nutrition,  it  is  necessary,  for  the  normal 
activity  of  the  organs  and  the  maintenance  of  health,  that  its  functions 
be  regularly  and  fully  performed.  But  retention  of  fecal  matter  beyond 
the  normal  period  is  one  of  the  most  common  ailments  both  in  infancy 
and  childhood,  and  occasionally  it  constitutes  a  grave  disease. 

Constipation  is  of  two  kinds,  namely,  sjjiiiptomatic  and  idiojjathtc. 

Symptomatic  Constipation.  Causes. — Many  of  these  are  ob- 
structive. The  more  common  of  them  are  the  following:  (a)  Congenital 
stenosis,  or  occlusion  of  the  anus  or  rectum.  The  anus  is  not  formed, 
or  it  terminates  in  a  cul-de-sac,  while  the  lower  end  of  the  large  intes- 
tines forms  another  cul-de-sac.  These  two  cul-de-sacs,  lying  opposite 
each  other,  one  looking  upward  and  the  other  downward,  may  be  sepa- 
rated from  each  other  by  a  small  interspace,  a  fibrous  septum,  so  that 
relief  can  be  obtained  by  a  puncture  or  incision,  or  they  may  be  widely 
separated,  so  that  there  is  no  possible  mode  of  relief,  and  death  is  in- 
evitable, unless  the  fecal  matter  escape  through  a  congenital  fistulous 
passage  upon  one  of  the  adjacent  mucous  surfaces,  which  mode  of  relief 
was  present  in  forty  per  cent,  of  the  cases  of  this  obstruction  collected 
by  Leichtenstern.  Exceptionally  this  malformation  occurs  in  the  sig- 
moid flexure,  while  the  rectum  is  normal.     The  stenosis,  if  slight,  may 


SYMPTOMATIC    C0X3TIPATI0X — CAUSES.  751 

produce  little  delay  in  the  evacuations,  except  when  hardened  masses  or 
coase,  indigestible  substances  descend  upon  it,  and  it  may,  therefore, 
with  careful  selection  of  diet,  cause  little  inconvenience  for  a  lengthened 
period,  while  much  stenosis  causes  early  obstructive  symptoms. 

Rarely  the  stenosis  is  at  the  ileo-CiBcal  orifice.  Thus,  in  the  Trans- 
actions of  the  Lond.  Path.  Soc,  for  1870,  is  the  history  of  a  case  in 
which  there  was  such  narrowing  of  the  ileo-ceecal  orifice,  believed  to  be 
congenital,  that  a  Xo.  9  catheter  could  barely  be  passed  through  it. 
The  patient  lived  till  his  thirty-second  year,  having  suffered  from  an 
early  age  with  frequent  attacks  of  colic  and  constipation.  After  his 
death,  the  ileum  next  to  the  ileo-ci^cal  valve  was  found  to  )\ave  a  diam- 
eter of  seven  inches,  while  the  large  intestine  was  much  atrophied,  and 
its  entire  lumen  contracted  from  the  long  disuse.  Occasionally,  the 
narrowing  occurs  a  little  above  the  ileo-csecal  orifice,  and  more  rarely  in 
the  duodenum,  at  the  point  of  union  of  the  pancreatic  or  bile-duct  Avith 
the  intestine.  In  the  last  situation,  the  obstacle  sometimes  appears  to  be 
hypertrophied  valvul;i3  conniventes,  the  edges  of  two  opposite  folds  be- 
coming more  or  less  adherent.  Such  congenital  intestinal  obstructions, 
whether,  as  is  probable,  produced  by  inflammations  in  the  fa'tus  or  from 
simple  perverted  nutrition;  whether  arising  from  syphilitic  cachexia  or 
other  cause,  of  course  retard  the  evacuations,  according  to  their  loca- 
tions and  the  degree  of  closure.  The  same  degree  of  stenosis  in  the 
colon  or  rectum  obviously  causes  more  constipating  effect  than  in  the 
small  intestine,  since  the  excrementitious  substance  is  firmer  in  the 
former  than  in  the  latter,  and  the  latter  have  more  mobility  by  which  to 
overcome  obstacles. 

{h)  Intestinal  Displacements. — These  produce  obstructions  of  a  very 
painful  and  dangerous  kind.  Intussusception  and  external  hernia  are 
too  well  known  to  require  description.  Both  are  likely  to  produce  com- 
plete obstruction  if  not  soon  relieved,  but  there  are  cases  of  intussuscep- 
tion in  children  in  which  the  displaced  intestine  remains  pervious,  and 
the  evacuations  occur  with  more  or  less  regularity;  and  the  same  is  true 
of  one  form  of  hernia,  namely,  the  congenital,  which,  although  painful, 
seldom  produces  serious  obstruction. 

Painful  and  dangerous  occlusion  and  consequent  arrest  of  al vine  evac- 
uations occasionally  result  from  the  imprisonment  of  a  loop  of  intes- 
tine in  an  opening,  usually  congenital,  in  the  mesenter}^  or  diaphragm, 
or  from  the  knotting  of  one  portion  of  intestine  with  another,  as  de- 
scribed by  Leichtenstcrn,  or  again  from  the  twisting  of  the  intestine. 
Epstein  and  Soyka'  relate  the  case  of  a  newborn  infiint  that  died  in  the 
second  week  after  birth  with  symptoms  of  obstruction.  At  the  autops}^ 
a  portion  of  the  small  intestine  with  its  mesentery  was  found  twisted 
upon  its  axis,  from  right  to  left,  without  any  marked  evidence  of  inflam- 
mation. 

('•)  Substances  which  have  been  swallowed,  or  substances  whose  nuclei 
have  been  swallowed,  and  which  consist  of  a  deposit  of  carbonate  and 
phosphate  of  lime,  or  substances  which  have  been  produced  entirely  in 
the  system,  and  which,  lodged  in  narrow  parts  of  the  intestine,  cause 

i  Centralb.  f.  d.  med.  Wissonscli.,  April  24,  1879. 


752  CONSTIPATION. 

obstruction.  Such  substances,  some  of  which  occur  most  frequently 
in  children,  and  others  in  eklerly  people,  produce  acute  constipation. 
Indigestible  matter  contained  in  the  food,  as  seeds  or  the  parenchyma- 
tous portions  of  fruits,  occasionally  collects  in  considerable  quantity  and 
obstructs  the  intestine.  A  large  gall  stone,  having  escaped  from  the 
common  bile-duct,  sometimes  lodges  in  the  intestine,  either  at  the  ileo- 
c?ecal  valve  or,  more  rarely,  at  some  other  point,  and  retards  the  pass- 
age of  fecal  matter.     But  this  seldom  occurs  in  children. 

In  one  instance,  and  in  only  one,  have  I  known  obstinate  constipa- 
tion to  be  produced  by  worms.  The  patient  Avas  a  girl  of  about  four 
years,  in  whom  constipation  came  on  suddenly,  and  was  accompanied  by 
distention  of  abilomen  and  great  suffering.  This  continued  nearly  one 
week,  wlien  a  mass  of  intertwined  round  worms  was  expelled,  with  im- 
mediate relief.  The  records  of  medicine  also  contain  cases  in  which 
neoplasms,  growing  from  the  coats  of  the  intestines  internally,  have  at- 
tained such  a  size  as  to  retard  the  evacuations. 

(d)  Abscesses  and  tumors,  especially  when  occurring  in  the  pelvis, 
also  sometimes  cause  constipation  by  ])ressing  upon  the  intestine,  and 
obstructing  or  narrowing  the  passage  through  it.  Thus,  in  18G8,  Mr. 
Thomas  Smith  related  to  the  London  Pathological  Society  the  case  of  an 
infant,  aged  fourteen  months,  in  whom  both  alvine  and  urinary  evacua- 
tions were  retarded  by  a  cancerous  tumor  growing  between  the  rectum 
and  bladder,  and  ending  fatally  in  three  months  after  the  occurrence  of 
the  first  symptoms. 

(c)  Peritonitis,  during  its  continuance,  is  known  to  constipate  the 
bowels.  It  is  supposed  that  inflammatory  oedema  occurs  around  the 
muscular  fibres  of  the  middle  coat,  by  which  their  contractility  is  im- 
paired. Hence  the  lax  state,  the  meteorism,  and  inaction  of  the  intes- 
tines in  this  disease.  When  the  peritonitis  abates,  the  normal  action  is 
restored,  and  the  evacuations  occur  i-egularly,  if  the  free  surface  of  the 
peritoneum  have  undergone  no  unfiivorable  change.  But  unfortunately 
peritonitis  often  produces  more  lasting  injury,  so  as  to  interfere  seriously 
with  the  intestinal  movements,  and  produce  an  habitually  torpid  state 
of  the  bowels.  This  occurs  from  adventitious  bands  of  inflammatory 
origin,  which  lie  across  the  intestines,  compressing  them  at  the  points 
of  contact,  and  restraining  their  movements,  and  from  adhesion  of  the 
intestinal  loops. 

The  most  marked  cases  which  I  have  observed  of  this  were  child»-en 
who  had  had  tubercular  peritonitis.  The  following  was  an  interesting 
example : 

Case. — Charles,  aged  4  years,  was  returned  to  the  New  York  Found 
ling  Asylum  on  April  16,  1877,  to  be  treated  for  tumor  albus  of  the  left 
knee,  and  for  general  ill-health.  His  parentage  and  early  history  were 
unknown.  The  nurse  in  the  city,  to  whom  he  had  been  entrusted  when 
quite  small,  stated  that  he  had  no  sickness  when  with  her,  except  sore 
eyes,  and  that  about  April  1,  1877,  the  enlargement  of  the  knee  was  firsi 
observed.  Tlie  head  of  the  biy  was  large,  and  the  abdomen  much  dis- 
tended, but  without  any  decided  tenderness  on  pressure ;  its  entire  lower 
part  had  a  purplish  color.  Percussion  over  it  gave  a  dull  sound,  except 
upon  and  near  the  epigastrium,  where  there  was  some  resonance  ;  unddli- 


SYMPTOMS.  753 

cus  prominent ;  circumference  of  body  over  abdomen,  23  inches ;  pulse 
128  ;  axillar}^  temperature  99^.  It  was  stated  that  he  had  uo  stool  with- 
out medicine,  and  that,  usually,  one  tablespoonful  of  castor  oil  was 
required  to  produce  it.  The  urine  contained  no  albumen,  and  was 
appa.rentlv  normal.  As  the  appearance  indicated  struma,  a  mixture  of 
cod-liver  oil,  syrup  of  the  lacto-phosphate  of  lime,  and  iron  was  pre- 
scribed, to  be  given  three  times  daily,  and  directions  wei'e  given  to  rub 
cod-liver  oil  over  the  abdomen  also  three  times  each  day,  for  five  minutes 
each  time.  Some  nodules  were  felt,  on  pressure  upon  the  abdomen,  which 
we  suspected  were  enlarged  mesenteric  glands.  From  the  day  on  which 
the  friction  and  kneading  of  the  abdomen  were  commenced,  the  stools 
began  to  occur,  on  the  average,  about  twice  daily.  The  kneading  proved 
the  safest,  as  well  as  most  efficient,  method  of  producing  defecation. 

On  May  4th,  the  circumference  of  the  trunk  over  the  most  prominent 
part  of  the  abdomen  was  reduced  to  twenty-two  inches.  The  records  on 
May  11th  state:  "Same  treatment  is  continued;  has  tolerable  appetite, 
but" is  pallid,  and  his  flesh  flabljy  and  soft."  On  May  22d,  the  circum- 
ference of  the  trunk  gave  22$  inches.  The  tumor  albus  remained  about 
the  same. 

I  saw  the  patient  again  during  attendance  in  the  asylum,  in  August  and 
Novemlier.  The  record  in  November  states  that  he  is  feeble  and  failing; 
is  l)ecoming  weaker  and  thinner ;  breath  and  exhalations  from  the  sur- 
face offensive  ;  he  is  kept  quiet  on  account  of  the  knee.  From  this  time 
he  gradually  failed,  and  died  April  11,  1878.  There  was  no  cough  to 
attract  attention;  and  instead  of  constipation,  a  diarrhoea  of  some  weeks' 
continuance  preceded  death. 

Autopsy. — Lungs  healthy,  except  a  little  exudation  over  the  summit 
of  rigiit  lung  ;  bronchial  glands  cheesy  ;  numerous  tubercles,  some  of  them 
cheesy,  upon  the  parietal  and  visceral  surface  of  the  peritoneum.  Loops 
of  the  intestines  were  united  to  each  other  by  old  adhesions,  and  the  small 
intestines  were  generally  bound  down  by  bands  into  a  "  uniform  con- 
glomeration;"  mesenteric  glands  enlarged  and  cheesy;  a  large  ulcer  upon 
the  surface  of  the  rectum,  and  numerous  small,  round  ulcers  upon  the 
surface  of  small  and  large  intestines,  apparently  occupying  the  site  of  the 
solitary  follicles. 

Occasionally,  a  false  band,  the  result  of  peritonitis,  lies  across  the 
intestines,  without  restraining  their  movements,  and  producing  no 
marked  symptoms,  and  probably  no  symptoms  at  all,  until  a  loop 
happens  to  pass  underneath  it,  wlicn,  if  not  soon  released,  it  is  liable  to 
become  strangulated,  with  complete  obstruction  to  the  passage  of  fecal 
matter.  This  displacement  might  properly  be  classified  with  the  inter- 
nal hernias  described  above.  In  my  own  person,  at  the  age  of  twelve 
years,  such  an  accident  occurred  about  two  months  after  the  peritonitis. 
Upon  the  abatement  of  the  inflammation,  a  sensation  of  traction  had 
been  noticed  in  tlic  umbilical  region,  almost  daily,  during  exercise,  and 
the  displacement  was  indicated  by  the  extreme  ])ain  which  characterizes 
such  cases,  and  which  ceased  suddenly,  when  the  parts  were  released 
after  al)out  eighteen  hours. 

(/)  While  it  is  important  that  the  diet  and  glandular  secretions 
should  be  such  that  the  feculent  matter  may  have  proper  consistence, 
for  easy  propulsion  along  the  intestinal  tube,  the  important  agent  by 
which  alvine  evacuations  arc  effected  is  obviously  muscular  contraction. 

4«   . 


754  CONSTIPATION, 

The  muscular  fibres  of  the  intestines  produce  the  vermicuhir  and  peri- 
staltic movements  by  which  the  excrement  is  carried  forward,  and  the 
abdominal  muscles,  by  their  powerful  contraction,  are  the  chief  agents 
of  expulsion.  Now  any  pathological  state  which  impairs  the  innerva- 
tion of  these  muscles,  or  renders  it  abnormal,  destroying  the  proper 
balance  between  "exciting  and  inhibiting  impulses,"  is  likely  to  cause 
constipation.  Hence  meningitis,  myelitis,  and  certain  other  diseases 
of  the  cerebro-spinal  axis,  rachitis,  general  weakness,  etc.,  are  com- 
monly attended  by  a  sluggish  state  of  the  intestines,  either  from  tonic 

contraction  of  the  muscular  fibres  of  the  middle  coat,  as  in  menineritis, 
1     ■  '  o       > 

or  paralysis. 

Idiopathic  Constipatiox.  Cause.-. — These  are  quite  numerous. 
The  more  prominent  of  them  are  the  fallowing.  First,  too  little  liquid 
in  the  excrement,  so  that  it  is  too  firm  for  ready  evacuation.  There 
may  be  too  little  liquid  taken  in  the  ingesta,  or  too  scanty  secretion  of 
the  liquids  which  mix  with  the  food,  as  those  of  the  pancreas,  liver,  and 
mucous  follicles,  or  there  may  be  too  great  an  absorption  of  liquid 
through  the  coats  of  the  intestines,  and  too  active  an  excretion  of  water 
from  the  skin,  kidneys,  or  lung.  The  firmer  the  fecal  matter,  the 
greater  the  tendency  to  constipation.  Those  who  lose  a  large  amount 
of  water,  as  in  diabetes,  night  sweats,  or  from  occupations  which  expose 
to  heat,  or  from  residence  in  a  hot  climate,  are  especially  liable  to  con- 
stipation, exccjjt  as  the  loss  of  liquid  is  compensated  by  an  increased 
amount  of  drink. 

The  character  of  the  food,  apart  from  the  amount  of  liquid  Avhich  it 
contains,  obviously  has  a  marked  influence  upon  the  consistence  and  fre- 
quency of  the  stools.  Occasionally,  the  intestines  act  sluggishly  from 
insufficiency  of  food.  Thus,  the  infant  sometimes  hangs  an  unusually 
long  time  on  the  breast,  and  the  mother  or  wet-nurse  l)elievcs  it  to  be  a 
hearty  nurser,  when  there  is  really  a  deficiency  of  milk,  and  the  stools 
are  scanty  and  infrequent  from  lack  of  material.  Again,  constipation 
is  not  uncommon  in  infimts  who  nurse  heartily,  and  seem  to  obtain  a 
sufficient  quantity  of  milk,  and  the  cause  of  it  is  not  in  the  state  of  the 
digestive  organs,  but  in  the  milk.  We  find  that  now  and  then  breast- 
milk  has  a  constipating  effect,  although  we  discover  nothing  to  cause 
this  result  in  the  mother's  diet  or  health.  The  compai'ison  of  ordinary 
milk  with  colostrum  may  furnish  a  clew  to  the  explanation.  Colostrum 
is  known  to  be  more  laxative  than  ordinary  milk,  and  it  differs  from  it 
chemically  in  containing  more  butter,  sugar,  and  salts.  Hence  the 
theory  seems  plausible  that,  when  breast-milk  is  constipating,  these 
elements  occur  in  less  than  the  novmnl  quantity.  And  we  shall  see  here- 
after that  treatment  suggested  by  this  theory  obviates  the  constipatior^. 

The  use  of  a  diet  which  consists  chiefly  of  assimilable  substances,  as 
animal  food,  and  from  which,  after  the  digestive  process,  little  coarse  and 
stimulating  residuum  remains,  is  obviously  liable  to  produce  a  sluggish 
state  of  the  boAvels.  On  the  other  hand,  coarse  food,  as  fruits  Avith  their 
seeds,  coarsely  ground  meal,  etc.,  which  stimulates  the  peristaltic  action 
and  the  secretions,  increases  the  number  and  frequency  of  the  alvine 
discharges. 

Habit  also  exerts  a  decided  influence  upon  defecation.     One  who,  for 


SYMPTOMS.  755 

whatever  reason,  neglects  or  resists  the  desire  for  a  stool,  soon  becomes 
less  conscious  of  the  daily  recurring  need,  and  establishes  a  constipated 
habit.  Constipation  is  more  liable  to  occur  in  those  who  lead  a  quiet 
life  than  in  those  who  are  active.  A  constipated  habit  is  established  in 
many  school  children,  by  neglecting  or  repressing  the  desire  for  a  stool, 
during  school  hours. 

But  there  are  cases  in  which  there  seems  to  be  a  constitutional  ten- 
dency to  constipation — a  tendency  quite  independent  of  the  usual  condi- 
tions. Thus  I  have  met  children  who  wex'e  bright  and  active,  free  from 
obstruction  or  disease  which  might  retard  the  evacuations,  apparently 
far  from  having  sluggish  muscular  contractility,  and  so  far  as  I  could 
see  with  proper  diet,  and  yet  with  defecation,  except  as  it  was  produced 
by  measures  employed,  occurring  no  oftener  than  each  second,  third,  or 
fourth  day. 

But  it  must  be  borne  in  mind  that  what  is  constipation  in  one  child 
may  not  be  in  another,  for  occasionally  one  does  well  with  only  one 
evacuation  every  second  or  third  day,  while  a  large  majority  re(|uire 
daily  defecation,  in  order  to  the  maintenance  of  perfect  health. 

In  the  adult,  the  sacculi  or  pouches  which  occur  in  the  walls  of  the 
colon,  produced  by  contraction  of  the  longitudinal  bands,  acting  at  right 
angles  to  the  direction  of  the  circular  fibres,  and  consisting  of  the  inter- 
nal  and  external  tunics,  without  the  muscular,  become  the  receptacles 
for  fecal  matter  in  those  who  are  constipated,  and  obviously  tend  to  in- 
crease the  constipation.  In  children  these  sScculi  are  much  less  devel- 
oped relatively,  and  in  yoifng  infants  whose  intestines  lack  the  longi- 
tudinal bands,  are  absent,  so  that  this  anatomical  condition  by  which 
the  passage  of  fecal  matter  is  delayed,  is  unimportant  as  a  cause  of  con- 
stipation in  the  young. 

Gautier,  of  Geneva,  Switzerland,  states  that  an  anal  fissure  is  a  com- 
mon cause  of  constipation  in  children.  Pain  in  defecation  when  such  a 
fissure  is  present  might  induce  children  to  resist  the  desire,  and  postpone 
the  act,  and  thereby  establish  a  constipated  habit,  but  if  such  fissures 
are  common  in  this  country,  except  in  syphilitic  infants,  they  have 
escaped  our  notice. 

Constipation  has  a  tendency  to  perpetuate  itself,  since  retained  fecu- 
lent matter  becomes  more  consistent  and  firmer,  and  the  contractile 
power  of  the  muscular  tunic  becomes  weakened  by  long  distention. 
Obviously,  also,  an  abnormal  length  of  the  large  intestine,  so  that  it 
doubles  on  itself,  whether  congenital  or  the  result  of  constipation,  and  a 
malposition,  which  diminishes  tlie  space  occupied  by  the  colon,  and 
therefore  increases  its  fiexures,  have  a  tendency  to  i>roducc  constipation. 

Symi'Toms. — When  there  is  a  mechanical  cause,  which  retarils  the 
passage  of  fecal  matter,  the  acuteness  of  symptoms  and  the  suffering  are 
generally  proportionate  to  the  degree  of  obstruction.  Symptomatic  con- 
stipation occurring  in  an  obstructive  disease,  whether  adhesions,  perito- 
neal bands,  intussusception,  knots  or  twisting  of  the  intestine,  incarce- 
ration in  a  false  passage,  or  from  biliary  or  intestinal  stones,  or  fecal 
masses,  is  attended  by  severe  symptoms,  such  as  intense  colicky  ])ain, 
VDinitmg,  loss  of  appetite,  and  rapid  prostration.  The  ingesta  accumu- 
late above  the  point  of  obstruction,  producing  distention  of  the  intestiu«> 


756  CONSTIPATION". 

with  fecal  matter  and  gas,  while  below  the  point  of  obstruction  the  in- 
testine is  soon  empty.  The  symptoms  indeed  have  the  severity,  and 
the  state  involves  tbe  danger,  ])resent  in  ordinary  strangulated  hernia ; 
while,  from  being  internal  and  therefore  less  accessible  for  treatment, 
tlie  danger  is  even  greater.  If  the  intestinal  tract  be  narrowed,  whether 
by  a  false  ligament,  the  result  of  an  old  peritonitis,  or  other  cause,  and 
there  be  still  perviousness,  so  that  excrementitious  matter  passes  by  the 
obstruction,  though  slowly,  and  with  more  or  less  difficulty,  the  patient 
mav  be  comparatively  comfortable,  if  the  food  be  such  that  no  hard 
masses  remain  ;  but  according  to  the  degree  of  stenosis  and  the  amount 
and  coarseness  of  the  fecal  matter,  symptoms  occur  referable  to  the  ob- 
struction. If  the  excrement  be  propelled  Avith  difficulty  through  the 
narrowed  part,  the  muscular  coat  above  the  obstruction  gradually  be- 
come? more  developed,  from  hypertrophy  of  the  muscular  fibres,  just  as 
the  heart  enlarges  from  obstructive  disease  of  its  valves,  while  below 
the  obstruction  the  intestine  atrophies,  and  its  calibre  diminishes  from 
disuse.  Colicky  pains,  accumulation  of  fecal  matter  above  the  obstruc- 
tion, distention  of  abdomen,  eructation  of  gas,  vomiting,  impaired  appe- 
tite, and  consequent  decline  of  the  general  health  are  common  results. 
There  is  constant  danger  in  these  cases  that  the  narrow  passage  may 
become  obstructed  by  fecal  matter,  if  it  happen  to  contain  hard  masses, 
or  coarse  indigestible  substances.  The  gravest  form  of  coRstipation  is 
obviously  that  due  to  mechanical  agencies  which  act  as  obstacles,  but  as 
the  obstacks  are  numerous,  diifercntly  located,  and  of  different  character, 
so  there  is  great  difference  in  the  gravity  of  the  cases. 

Idiopathic  constipation  generally  comes  on  gi-adually.  It  at  first  at- 
tracts little  attention  and  is  neglected.  The  symptoms,  of  course,  vary 
greatly  according  to  tbe  degree  and  stage  of  constipation.  In  mild 
cases,  the  retention  is  only  in  the  rectum,  or  rectum  and  sigmoid  flex- 
ure, and  there  are  no  marked  symptoms  except  a  sensation  of  fulness  or 
distention  of  these  parts,  which  one  or  two  evacuations  relieve.  Be- 
tween these  mild  cases  and  the  graver  forms  of  constipation,  there  is 
every  intermediate  grade,  attended  by  symptoms  proportionately  severe. 
It  is  surprising  sometimes  to  observe  hoAV  long  patients  live  with  ex- 
treme constipation,  though  with  constant  suffering  and  ill-health,  and, 
which  I  wish  especially  to  be  noticed  in  this  connection,  a  large  propor- 
tion of  the  fiital  cases  of  idiopathic  constipation  occurring  in  adults, 
and  recorded  in  the  literature  of  the  profession,  began  early  in  life,  even 
in  infancy,  at  which  time  they  probably  might  have  been  relieved  by 
proi)er  medical  measures,  and  a  life  of  suffering  prevented.  This  im- 
portant practical  fact  shows  the  need  of  greater  attention  on  tlie  part  of 
parents  and  nurses  to  the  state  of  the  bowels  in  children,  that  their  slug- 
gish action  may  be  corrected  before  it  becomes  habitual,  and  those  ana- 
tomical changes  of  distention  and  muscular  paralysis  occur,  Avhich  are 
with  difficulty  corrected.  Thus  among  the  older  authenticated  cases 
is  one  related  by  Dr.  Copeland,  in  his  Medical  Dictionary,  from  Re- 
nauldin. 

Cast:. — A  medical  officer  in  the  French  service  was  always  costive  from 
birth,  he  ate  larnelv,  but  f^eldom  pussed  a  stool  oftener  than  once  in  one  or 
two  months,  and  his  abdomen  assumed  a  large  size.     At  the  age  of  forty- 


SYMPTOMS.  757 

two,  his  constipation  was  usually  prolonged  to  three  or  four  months.  In 
1806,  after  medicines  had  been  taken  to  procure  a  stool,  which  had  not 
been  passed  for  upward  of  four  months,  abundant  evacuations  continued 
for  nine  days,  and  contained  the  stones  of  raisins  taken  a  twelvemonth 
before ;  but  the  constipation  returned.  In  1809  the  enlarged  abdomen 
became  painful,  vomiting  supervened,  and  he  died  at  the  age  of  fifty-f  )ur, 
having  seldom,  through  life,  passed  more  than  four,  five  or  six  stools  in 
the  year.  On  opening  the  abdomen,  a  fibrous  partition  obstructed  the 
rectum,  about  an  inch  from  the  anus. 

A  case  quite  as  remarkable,  and  of  recent  date,  occurred  in  the  prac- 
tice of  Dr.  Strong/  of  Westfield,  jS".  Y. 

Case. — This  patient,  at  the  age  of  two  years,  usually  had  one  stool  in 
two  weeks,  and  several  years  later  only  one  in  six  weeks.  When  an  a<lult 
he  was  treated  bv  Dr.  Strong,  who  found  great  distention  of  the  al)domen, 
so  that  the  lower  ribs  were  pressed  outward  in  nearly  a  horizontal  direc- 
tion, and  the  thoracic  organs  upward,  so  that  the  apex  beat  of  the  heart 
was  about  one  inch  above  the  nipple.  At  this  time,  months  elapsed  be- 
tween the  stools,  the  longest  intervals  being  eighteen  months  and  sixteen 
davs.  Defecation  when  it  did  occur  lasted  from  two  to  four  days,  and 
was  attended  by  violent  gastric  and  intestinal  pain,  vomiting,  and  pros- 
tration. At  one  of  these  prolonged  stools,  forty  pounds  of  feces,  resera- 
bliuLT,  as  it  usually  did,  chewed  brown  paper,  were  evacuated,  the  quan- 
titv  being  accurately  ascertained  by  weighing  the  patient  before  and  after- 
ward, lie  h:id  appetite  and  was  able  to  do  eertaiu  kinds  of  farm  work 
during  the  year  preceding  his  death,  which  occurred  at  the  age  of  twenty- 
eight  years.  At  the  autopsy  the  colon  was  found  to  have  a  length  of  six 
feet  and  three  inches,  and  a  circumference  of  thirteen  inches,  while  the 
lungs  were  i)ressed  upward  and  backward,  as  when  compressed  by  a  pleu- 
ritic exudation. 

While  such  extreme  cases  are  infrequent,  all  physicians  of  experience 
are  consulted  from  time  to  time  by  adults  Avho  have  had  habitual  consti- 
pation from  tlieir  earliest  recollection,  and  these  cases,  that  aggregate  so 
large  a  number,  might,  there  is  little  reason  to  doubt,  have  been  pre- 
vented for  the  most  part  during  childhood,  when  the  habit  was  being 
formeil. 

In  long-continued  consti])ation,  in  which  there  is  a  large  fecal  accu- 
mulation, not  only  is  the  diameter  of  the  colon  increased,  as  stated 
above,  but  tliis  part  of  the  intestine  becomes  elongated.  This  may  lead 
to  change  in  its  position,  the  curves  of  tlie  sigmoid  flexure  extending 
further  to  the  right,  and  tlie  centi-al  part  of  the  transverse  colon  by  its 
weiiilit  curving  downward.  This  abnormal  lengthening  and  the  conse- 
<(uent  curvatures  have  a  tendency  to  increase  tlie  constipation,  as  has 
been  stated  above  in  our  remarks  rehiting  to  the  etiology. 

In  these  cases  of  extreme  constipation,  which  fortunately  are  rare  in 
children,  as  they  are  also  in  adults,  the  distention  of  the  colon  at  the 
ileo-ciccal  orifice  has  a  tendency  to  widen  this  orifice,  so  that  the  valve 
which,  in  the;  ordinary  state,  ju'events  the  return  of  any  substance  which 
has  once  jtiissed  l)y  it,  is  liable  to  become  insufficient.     The  adjacent 

'   Amor.  Juiirn.  of  Med.  Sci.,  1874  and  187(3. 


753  COXSTIPATION. 

folds  Avhicli  constitute  the  valve  become  separnted,  so  that,  if  vomiting 
and  antiperistaltic  movements  occur,  fecal  matter  may  pass  from  the 
colon  toward  the  stomach.  In  aggravated  cases,  in  whicli  tliere  is  re- 
tention of  a  large  amount  of  fecal  matter,  distention,  muscular  paralysis, 
etc.,  similar  to  those  Avhich  "we  have  seen  produced  in  the  colon,  are 
liable  to  occur,  though  to  a  less  extent,  in  the  small  intestines,  especially 
in  the  ileum. 

Retained  excrementitious  matter  accumulating  in  large  masses  evi- 
dently becomes  an  irritant,  so  that,  by  its  pressure,  it  excites  muscular 
contractions,  which,  if  ineffectual  in  propelling  the  mass,  cause  colicky 
pains.  The  retained  fecal  matter  also  undergoes  more  or  less  decom- 
position, producing  gases  which,  by  increasing  the  distention,  also 
increase  the  pain. 

Any  irritating  substance  applied  to  a  mucous  surface  is  liable  to  excite 
increased  secretion  from  the  mucous  follicles  or  from  the  glands  whoso 
orifices  connect  with  the  mucous  membrane  at  the  point  of  irritation. 
Many  familiar  examples  will  at  once  be  recalled  to  mind,  as  the  defluxion 
from  the  nostrils  from  the  use  of  snuffs,  and  increased  mucous  secretion 
and  salivation  from  objects  held  in  the  mouth.  In  the  same  way,  re- 
tained excrement,  f  )rming  hard  masses  which  press  upon  the  intestinal 
surface,  excite  a  secretion,  and  not  infrequently  produce  thereby  a  diar- 
riitea  which  is  conservative,  and  which  may  for  the  time  unload  the 
bowels,  or  it  may  remove  a  part  of  the  scybalse,  while  the  rest  remain. 
Hence  we  sometimes  hear  patients  speak  of  having  irregular  evacua- 
tions, constipation  alternating  with  diarrhoea.  In  aggravated  cases,  the 
pressure  of  impacted  feces  sometimes  produces  inflammation  of  the  sur- 
face, when,  in  addition  to  abdominal  pain,  there  are  tenderness  on  pres- 
sure and  some,  usually  quite  moderate,  febrile  movement.  In  cases 
■which  have  terminated  fatally,  after  a  longer  or  shorter  time,  destruc- 
tion of  the  mucous  surface  has  been  found  in  places,  in  consequence  of 
the  pressure  and  inflammation.  Thus,  in  the  history  of  the  French 
officer  related  above,  it  is  stated  that  the  inner  surface  of  the  distended 
intestine  "presented  gangrenous  and  ulcerated  patches."  We  can 
readily  believe  that,  as  in  cases  of  typhoid  ulcerations,  if  the  ulcers 
reach  a  certain  depth,  they  may  also  give  rise  to  localized  peritonitis, 
and  that  occasionally  perforation  may  result  at  the  vdcerated  or  gan- 
grenous point.  Tlie  expulsion  of  hardened  masses  which  have  collected 
in  the  rectum  is  slow  and  painful,  and  accompanied  by  more  or  less 
tenesmus,  which  not  infrequently  causes  a  ])ortion  of  the  mucous  mem- 
brane at  the  anal  orifice  to  descend  below  the  sphincter  ani  and  pro- 
trude, by  which  hemorrhoids  are  produced.  Occasionally,  as  I  have 
observed  in  certain  cases,  the  entire  circumference  of  the  rectal  mucous 
membrane,  to  the  distance  of  half  an  inch  or  more  above  the  anus, 
becomes  so  loosened  from  its  attachment  to  the  connective  tissue  that  it 
descends  below  the  sphincter  ani,  and  protrudes  during  each  defecation. 
But  this  displacement,  known  as  prolapsus  recti,  more  commonly  re- 
sults, in  children,  from  protracted  intestinal  catarrh,  attended  by  diar- 
rh(jea,  loss  of  flesh,  and  by  diminished  tonicity  of  the  tissues. 

A  beautiful  and  conservative  provision  in  the  system  is  that  by 
which  vicarious  functions  are  established  to  relieve  organs  which  imper- 


T  K  E  A  T  :S[  E  X  T  ,  759 

fectly  perform  their  part.  Wliile  the  intestinal  surface  is  to  a  great 
degree  eliminative,  so  that  noxious  and  eft'ete  products  are  largely  ex- 
pelled from  the  system  in  the  stools,  it  possesses  also,  in  high  degree, 
an  absorbent  function,  as  all  who  employ  rectal  alimentation  are  aware. 
Now,  if  the  intestine  fail  to  perform  its  function  of  defecation,  and  fecu- 
lent matter  collect  within  it.  and  begin  to  exert  pressure  upon  the  intes- 
tinal surface,  more  or  less  of  the  liquid  portion  is  taken  up  by  the  ves- 
sels, and,  entering  the  general  circulation,  finds  a  mode  of  escape  through 
other  ernunctories.  The  general  ill-health  or  languor,  the  furred  tongue, 
headache,  and  foul  breath  which  characterize  these  cases  are,  no  doubt, 
due  to  the  absorption  into  the  blood,  or  retention  in  it  of  noxious  pro- 
ducts contained  in,  and  which  in  part  constitute,  the  feculent  matter. 
The  fact  that  patients  may  live  for  years  with  tolerable  appetite,  and 
with  only  one  dejection  every  second  or  third  week,  receives  explanation 
in  the  fact  that  other  organs,  as  the  lungs,  kidneys,  skin,  etc.,  act  as 
depurants  for  such  excrementitious  matter  as  can  be  taken  up  in  a 
liquid  or  gaseous  form  by  the  intestinal  surface. 

In  infants,  constipation,  even  when  slight  and  tempoi'ary,  often 
causes  fretfulncss,  which  is  indicated  by  the  character  of  their  cries  and 
the  movement  of  the  thighs  over  the  abdomen.  Continuing  for  a  time, 
it  causes  more  or  less  fever,  and,  in  those  young  children  who  are 
liable  to  eclampsia,  it  predisposes  to  an  attack,  and  it  may  be  the 
chief  cause. 

Treatment. — If  tliere  be  reason  to  suspect  the  presence  of  a  mechan- 
ical obstacle  Avhich  prevents  normal  defecation,  a  careful  examination 
should  be  made,  in  order  to  discover,  if  possible,  its  nature  and  loca- 
tion. Often  it  is  of  such  a  nature  that  it  cannot  be  removed,  but  its 
constipating  effects  may  sometimes  be  in  a  measure  obviated.  In  the 
case  related  above,  in  which  constipation  continued  from  early  child- 
hood to  adult  life,  and  finally  j)roved  fatal,  its  cause  was  ascertained  to 
be  a  septum  in  the  rectum,  which  probably  might  have  been  relieved  by 
surgical  measures.  In  all  cases  of  constipation,  which  the  history 
shows  may  be  ])roduced  by  mechanical  causes,  Avhether  the  obstruction 
be  complete  and  the  colicky  pains  and  other  symptoms  severe,  or  there 
be  occasional  scanty  evacuations.  Avitli  but  slight  or  moderate  suffering, 
the  history  of  the  patient  should  be  obtained,  in  order  to  ascertain  if 
tliere  had  been  at  any  previous  time  symptoms  of  peritonitis  or  other 
pathological  state  which  mipit  throv/  lijrlit  on  th«  etiology.  The  abdo- 
men and  the  usual  sites  of  liernia  should  be  carefully  explored  by  pal- 
pation, and  tlie  rectum  by  tlie  finger,  large  size  catheter,  or  rectal  tube. 
A  thorougli  examination  thus  instituted,  painless  to  tlie  patient,  will 
usiiallv  emible  tlie  practitioner  to  determine  either  the  ex.ict  or  probable 
obstacle,  if  any,  be  present. 

The  proper  treatment  of  symptomatic  constipation  obviously  requires 
the  removal,  so  far  as  possible,  of  the  primary  disease,  or  the  cause, 
^vl'ither  it  be  obstructive  or  otherwise,  and  we  need  not  stop  to  consider 
the  special  measures  which  are  reciuired,  and  will  })ass  to  the  considera- 
tion of  tlie  treatment  of  idiojjathic  constipation. 

Ilijllicjiic  Measures. — We  have  already  alluded  to  the  fact  that  hal)it 
has  a  prnverful  control  over  the  action  of  the  intestines,  so  that  it  is  im- 


7(50  COXSTIPATIOX, 

portant  to  oljtain  a  daily  alvine  evacuation  at  a  certain  hour,  and,  by 
establishing  the  habit,  the  need  Avill  usually  be  experienced  when  that 
hour  arrives  each  day.  Many  cases  ■svhich  become  troublesome  and  ob- 
stinate might,  no  doubt,  have  been  prevented,  had  this  ])liysiological  law 
been  heeded,  and  a  daily  evacuation  obtained  at  a  certain  hour.  The 
constipated  habit,  mild  and  not  yet  fully  established,  is  more  liable  to  be 
overlooked  when  it  occurs  in  childhood  than  in  infancy,  for  the  infant  is 
closely  and  constantly  under  observation,  and  it  soon  presents  synii)t()ms, 
as  fever  and  fretfulness,  if  it  do  not  have  the  regular  evacuation,  while 
children  over  the  age  of  four  or  five  years  tolerate  better  a  sluggish  state 
of  the  bowels,  and  are  likely  to  be  constipated  for  a  considerable  time 
before  it  is  ascertained.  They  therefore  require  more  attention,  in  this 
regard,  than  is  usually  bestowed  by  parents. 

The  nature  of  the  diet  is  obviously  important,  as  certain  kinds  of  food 
are  more  laxative  than  others.  Chicken-tea,  and,  to  a  certain  extent, 
beef  and  mutton  tea,  are  laxative,  and,  made  plainly,  are,  therefore,  use- 
ful in  connection  with  other  articles.  The  various  kinds  of  berries  and 
fruits  have  also  a  decidedly  stimulating  effect  on  the  intestinal  surface, 
and  aid  in  removing  constipation.  The  apple  scraped  or  baked,  or 
apple-sauce,  may  be  given  to  quite  young  children  ;  and  for  those  that 
are  older,  currants,  cherries,  and,  among  dry  fruits,  prunes  and  figs  are 
laxative.  Unfermented  cider,  in  its  season,  Avhich  has  been  found  so 
useful  for  adults,  may  also  be  given  to  children  in  moderate  quantity,  at 
least  to  those  who  have  reached  the  age  of  two  or  three  years. 

By  the  digestive  process,  starch,  wdiich  is  unassimilable,  is  changed 
into  glucose,  which  can  be  absorbed  and  assimilated,  and,  from  the  small 
size  of  the  salivary  glands  in  the  first  months  of  infancy,  it  is  believed 
that  the  salivary  and  pancreatic  fluids  are  insufficient  to  convert  starch 
into  glucose  except  in  very  inadequate  quantity.  It  appears,  however, 
highly  probable  that  there  is  an  epithelial  ferment,  which  converts  starch 
into  sugar',  so  that  young  infants  can  digest  starchy  food  in  limited 
quantity.  The  belief  that  the  infantile  digestion,  up  to  a  certain  age,  is 
inade(|uate  to  effect  the  change,  led  to  the  preparation  of  food  for  infants, 
in  which  the  change  of  starch  into  glucose  was  accomplished  by  a  chem- 
ical process.  Now  glucose,  given  in  considerable  quantity,  is  laxative, 
and  I  have  found  it  necessary  to  give  the  glucose  preparation  sparingly, 
and  w'ith  other  food  in  the  hot  months,  when  infants  are  so  prone  to 
diarrhoea.  But  this  laxative  effect  renders  the  glucose  preparations  of 
the  shops  very  useful  in  the  treatment  of  habitual  constipation  of  infants, 
whether  we  employ  the  "maltose  "  or  "granulated  sugar  of  malt,"  or 
the  preparations  of  Liebig's  food.  Of  four  constipated  infants  in  the 
New  York  Infant  Asylum,  to  whom  Ilorlick's  "sugar  of  malt"  was 
given,  three  Avere  relieved.  Any  of  the  glucose  preparations  can  be 
given  quite  freely  to  a  constipated  inflmt,  Avithout  im})airing  the  diges- 
tive function,  or  producing  other  ill-effect,  so  long  as  no  more  than  the 
normal  evacuations  are  produced  ;  and  I  consider  them  among  the  best 
and  safest  of  the  foods  for  tlie  relief  of  constipation  in  infants,  but 

'  Chemical  Phenomena  of  Digestion,  by  Charles  Richet,  Rev.  de,  Sci.  Med., 
Oct.  1878. 


T  RE  ATM  EXT.  761 

glucose  or  grape  sugar  is  only  feebly  laxative,  probably  not  more  than 
cane  sugar. 

Oatmeal  is  more  laxative  than  most  other  kinds  of  amylaceous  food. 
Made  into  a  gruel  and  strained,  it  may  be  given  to  the  nursing  infant, 
and  unstrained  to  those  who  are  older.  Bread  or  pudding  from  coarsely 
ground  or  unbolted  flour  or  meal,  and  vegetables  which  contain  saline 
r.nd  fibrous  substances,  have  a  stimulating  and  laxative  e.flfect  on  the  sur- 
face of  the  intestines,  and,  therefore,  are  useful  for  constipated  children 
of  the  age  of  two  or  three  years  and  upward. 

There  can  be  no  doubt  that  the  free  use  of  water  in  the  ingesta  mate- 
rially aids  in  relieving  costiveness.  In  one  of  the  numbers  of  the  Lon- 
don Lancet,  a  physician  asks  the  profession  how  to  cure  obstinate 
constipation  in  adults.  Among  the  replies,  one  physician  suggests 
drinkin<2;  a  tumblerful  of  cold  water  on  retiring;  to  bed,  and  another 
tumblerful  in  the  morning,  and  there  can,  I  think,  be  little  doubt  that 
the  laxative  eifect  of  broths,  gruels,  fruits,  and. mineral  waters  is  partly 
due  to  the  amount  of  water  which  they  contain.  One  of  the  chief 
causes  of  constipation,  Ave  have  seen,  is  too  great  firmness  or  consistence 
of  the  stools,  due  to  absorption  of  the  water,  and  if  a  larger  quantity 
of  water  be  swallowed  during  or  after  the  meals  than  is  remov'ed  by 
absorption,  so  tliat  the  stools  have  their  normal  or  less  than  normal 
consistence,  this  cause  of  constipation  is  removed.  An  excess  of  water 
introduced  into  the  system  is  to  a  great  extent  eliminated  by  the  kid- 
neys, and,  in  hot  weather,  by  tlie  skin,  and,  to  a  certain  extent,  exhaled 
from  the  lungs ;  but  experience  shows  that,  if  the  amount  of  liquid 
received  be  so  great  that  the  vessels  in  the  coats  of  the  intestines  con- 
tinue in  a  state  of  repletion,  only  a  certain  part  of  it  is  absorbed,  while 
the  rest  descends  and  mixes  with  the  excrementitious  matter. 

The  simple  expedient  of  allowing  a  liberal  use  of  water,  so  useful  in 
adult  cases,  doubtless  also  has  a  laxative  effect  in  children,  and  its  judi- 
cious use  is  proper  for  them.  Another  important  aid  in  overcoming 
habitual  constipation  is  frecjuent  kneading  of  the  abdomen.  My  atten- 
tion was  first  particularly  directed  to  this  in  the  treatment  of  the  case 
related  above,  in  which  obstinate  constipation,  occurring  in  a  child  of 
three  years  from  peritoneal  bands  and  adhesions,  was  to  a  great  extent 
corrected  by  friction  over  the  abdomen  for  three  or  four  minutes  at  a 
time  with  cod-liver  oil,  three  or  four  times  daily.  Tiie  manipulation 
])i<)bably  did  the  good,  and  not  tlie  oil,  but  the  use  of  one  of  the  oils  for 
inunction  renders  the  kneading  less  painful,  and  insures  its  more 
thorough  performance  by  the  nurse.  All  obstetricians  in  certain  emer- 
gencies stimulate  the  uterine  muscular  fibres  to  contraction  by  kneading 
the  abdomen,  and  it  is  probable  that  the  muscular  fibres  of  the  intes- 
tines are  stimidate<l  in  a  similar  manner,  so  that  the  intestinal  move- 
ments are  increased  by  which  feculent  matter  is  carried  forward. 

The  external  application  of  cold,  so  effectual  in  contracting  the  uter- 
ine muscular  fibres,  also  stimulates  the  contractile  power  of  the  muscular 
fibres  of  the  intestines.  Gold-watcr  bathing,  the  sudden  ai>plication  of 
a  cloth  wrung  out  of  cold  water  to  the  abdomen,  and  in  certain  ob- 
stinate cases  even  the  douche,  may  be  used  to  stimulate  the  muscular 
coat   of  the  intestines  and   the  abdominal   muscles  to  greater  activity. 


762  COXSTIPATION  , 

Trousseau  says:  "Before  leaving  the  subject  of  the  treatment  of  con- 
stipation, let  me  refer  to  the  application  of  cold  to  the  abihnaen — a 
minor  method,  which  I  have  seen  recommended,  and  have  myself  pre- 
scribed with  astonishing  success.  On  rising  in  the  morning,  let  there 
be  placed  on  the  abdomen  a  compress  of  several  folds  soaked  in  cold 
water,  and  let  it  be  separated  from  the  clothes  by  a  sheet  of  gutta-percha 
or  caoutchouc.  This  compress  ought  to  remain  on  for  three  or  four 
hours."  This  recommendation  by  Trousseau  is  for  adults,  who  are 
much  less  susceptible  to  the  influence  of  cold  than  children.  So  pro- 
longed an  application  of  cold  and  wet  to  a  child,  even  the  most  robust, 
would  involve  danger,  while  its  application  during  the  brief  period  oc- 
cupied in  an  ordinary  bath,  with  proper  exercise  afterward,  or  with 
other  measures  to  prevent  chilling,  could  have  no  ill-effect. 

Therapeutic  Pleasures. — For  temporary  constipation  and  many  cases 
that  are  habitual,  enemata  should  be  employed,  since  they  promptly''  un- 
load that  part  of  the  intestines  in  Avliich  feculent  matter  is  ordinarily 
retained,  while  they  do  not  impair  the  appetite  or  produce  the  prostra- 
tion which  so  often  results  from  purgatives.  For  temporary  constipa- 
tion, a  warm  clyster  may  be  given,  and  it  commonly  is  more  agreeable 
to  the  patient  than  one  of  lower  temperature  than  the  body.  Among 
the  enemata  v/hich  have  been  found  useful  are  castile  soap,  with  molas- 
ses and  water,  salt  and  water,  the  various  oils,  as  sweet  oil,  with  or  Avith- 
out  castor  oil,  linseed  oil,  alone  or  with  molasses,  and  the  gruels,  as  that 
of  oatmeal  or  cornmeal  made  thin.  The  belief  that  the  frequent  use 
of  warm  clysters  produces  a  relaxing  effect  is  probaldy  correct,  so  that, 
if  it  be  necessary  to  employ  clysters  often,  in  consequence  of  the  torpid 
state  of  the  intestines,  cool  water,  the  effect  of  which  is  tonic  and  stimu- 
lating, should  be  used. 

For  infants,  a  clyster  of  one  or  two  ounces  usually  suffices,  adminis- 
tered by  a  gutta-percha  or  glass  syringe,  while  for  older  patients  a  pro- 
portionately larger  quantity  is  required,  administered  by  preference 
through  a  Davidson,  India-rubber,  or  a  fountain  syringe.  In  certain 
long-continued,  aggravated  cases,  the  frequent  injection  of  a  large  quan- 
tity of  tepid  water  is  indispensable,  in  order  to  wash  away  the  accumu- 
lation of  fecal  matter.  Thus,  in  1854,  Mr.  Gay  exhibited  to  the  London 
Pathological  Society  a  boy  of  seven  years,  who  at  the  age  of  three  years 
had  had  typhus  fever  with  dysenteric  stools.  After  convalescence,  he 
had  habitual  obstinate  constipation,  so  that,  when  Mr,  Gay  began  treat- 
ment, there  had  been  no  fecal  evacuation  for  nearly  four  months,  and 
the  girth  of  the  body  over  the  abdomen  was  forty-nine  inches,  and  yet 
the  appetite  and  general  health  were  not  seriously  impaired.  The  shape 
of  the  abdomen  and  the  examination  showed  great  distention  of  the 
rectal  ampulla  and  the  descending  colon.  Mr.  Gay  first  distended  the 
sphincter  ani,  so  that  it  admitted  a  speculum,  and  through  a  rectal  tube, 
well  introduced  into  the  colon,  the  excrement  was  repeatedly  washed 
away,  so  that  at  the  time  of  the  exhibition  of  the  boy  to  the  Society,  the 
measurement  in  girth  gave  only  twenty-four  inches.  Evidently  in  cases 
like  the  above,  no  other  treatment  except  repeatedly  washing  out  the 
intestines  with  warm  water  would  have  answered,  and  the  dilatation  of 


TREATMENT.  763 

the  sphincter  ani  and  the  introduction  of  the  speculum  to  facilitate  the 
escape  of  fecal  matter  are  noteworthy. 

Suppositories  may  sometimes  be  usefully  employed  in  place  of  ene- 
mita;  cocoanut  butter,  molasses  candy,  or  soap  cut  in  shape  of  a  pencil 
may  be  used  for  this  purpose.  In  the  adult,  long-continued  constipa- 
tion is  not  very  rare,  in  which  the  rectal  ampulla  becomes  so  impacted 
that  it  is  necessary  to  use  the  anal  curette,  the  handle  of  a  spoon,  or  the 
finger  introduced,  in  order  to  break  up  the  masses,  and  allow  them  to 
pass.  In  children,  necessity  for  such  treatment  is  much  more  rare,  but 
there  are  occasional  cases  like  that  above  described  by  Mr.  Gay,  in 
Avhich  it  m.iy  be  needed.  Dr.  Nagcl  states  that  the  evil  may  be  removed 
by  the  introductiDu  of  a  suppository  of  brown  gelatine.  This  is  steeped 
in  Avater  for  twelve  hours,  and  having  been  thus  softened,  is  introduced 
into  the  rectum,  and  an  evacuation  obtained.  The  doctor  attributes  the 
laxative  eifect  to  the  hygrometric  action  of  the  gelatine. 

The  known  effect  of  the  galvanic  current  in  producing  contraction  of 
the  uterine  muscular  fibres  suggests  its  employment  to  relieve  constipa- 
tion, by  stimulating  the  muscles  of  the  abdomen  and  the  muscular  coats 
of  the  intestines,  ami  those  who  have  employed  it  speak  favorably  of  its 
use.  Ilabershon  says:  '•  A  galvanic  current,  transmitted  through  the 
abdominal  walls,  induces  a  very  speedy  action,  or  rather  emi)tying  of 
the  colon.  ...  A  case  of  partial  paraplegia,  in  which  injections 
did  not  act  satisfactorily,  and  drastic  purgatives  Avere  undesirable,  Avas 
treated  Ity  a  galvanic  current  passed  tlirough'the  aljdomen  every  morn- 
ing. In  a  few  hours  a  free  evacuation  Avas  produced  Avithout  any  dis- 
comfort." But  the  constipation  of  children  very  seldom  requires  the 
use  of  galvanism. 

The  ordinary  purgatiA^es  should  not  be  given  habitually  to  relieve  a 
constipated  habit.  They  are  liable  to  irritate  the  intestines,  causing  a 
catarrh,  or  else  the  intestines  become  accustomed  to  their  action,  and  a 
large  dose  is  needed  to  effect  purgation.  Given  habitually,  they  cannot 
fiiil,  also,  to  disturb  the  digestive  and  nutritive  processes.  One  or  tAvo 
doses  for  present  relief,  both  in  habitual  or  temporary  constipation,  is 
sometimes  required,  provided  that  an  injection  is  for  any  reason  not 
preferred.  For  this  purpose,  castor  oil  or  a  few  grains  of  calomel  mixed 
Avith  syrup  of  rliubarb,  tbe  syrup  of  senna,  or  the  compound  li([Uorice- 
pOAvder  of  tbe  German  Pharmacojineia  niay  be  administered  Avith  ad- 
vantage. But  for  habitual  constipation  I  strongly  advise  to  discard  the 
ordinary  purgative  medicines,  and  if  the  measures  of  a  dietetic  or 
hygienic  character,  recommen<led  above,  arc  not  sufficient,  to  employ 
such  remedial  agents  as  promote,  or  at  least  do  not  impair,  nutrition. 

Belladonna,  so  highly  recommended  by  Trousseau  and  others,  I  have 
often  administered  to  children,  especially  in  pertussis,  in  large  doses 
during  several  consecutive  days,  but  it  has  not  seemed  to  me  to  have 
any  decided  laxative  effect.  Though  it  may  be  useful  in  certain  mix- 
tures for  adults,  our  experiences  in  this  country,  Avith  reliable  prepara- 
tions, certainly  have  not  been  such  as  to  justifv  its  employment  as  the 
sole  or  main  remedy  for  constipation.  It  diminishes  rellex  iri'itability, 
and  may  rcmlcr  tbe  action  of  j»urgatives  less  painful,  l>ut  from  its  known 
physiological  effects  Ave  cannot  believe  that  it  increases  the  intestinal 


7(34:  CONSTIPATIOX. 

secretions  or  the  action  of  tlie  muscular  fibres,  one  or  the  other  of  which 
results  we  expect  from  the  use  of  an  agent  which  is  really  laxative.  On 
the  other  hand,  nux  vomica  and  its  active  principle,  strychnia,  are 
doubtless  valuable  adjuncts  to  purgative  mixtures,  from  their  eftect  in 
increasing  the  action  of  muscular  fibres. 

Physicians  are  not  infrec^uently  at  a  loss  what  to  prescribe  for  the 
habitual  constipation  of  nursing  infants,  which  is  by  no  means  infre- 
quent. But  recollecting  that  the  colostrum  is  more  laxative  than  ordi- 
nary milk,  and  that  it  differs  from  it  in  containing  more  sugar,  salts 
(largely  phosphates),  and  butter,  we  have  a  hint,  as  stated  above,  as  to 
what  is  probably  lacking  in  the  milk,  and  what,  therefore,  should  be 
supplied.  I  am  in  the  habit  of  giving  the  oil,  sugar,  and  salts  in  the 
following  formula,  and  usually  with  the  desired  laxative  eifect : 

R. — 01.  niorrhure    ........  2  parts. 

Aq.  calcis, 

Syr.  calcis  laetopbos.       ......     afi  1  part. 

One-quarter,  one-third,  or  one-half  teaspoonful  may  be  given  with 
each  nursing,  or  a  larger  quantity,  as  a  teaspoonful  or  more,  three  times 
daily.  Breast-milk  with  this  addition  becomes  more  nearly  like  colos- 
trum in  its  laxative  properties,  while  it  does  not  possess  those  properties 
of  colostrum  which  disturb  the  digestive  process.  I  know  no  agent  of  a 
medicinal  nature  which  meets  the  indication  so  well  as  this  for  infantile 
constipation.  But  in  my  practice  I  have  found  it  necessary,  in  not  a 
few  instances,  to  rely  mainly  on  simple  enemata  for  the  relief  of  the 
constipated  habit,  till  the  infants  reached  the  age  when  a  mixed  diet 
was  proper. 

The  habitual  constipation  of  older  children  may  ordinarily  be  relieved 
by  the  remedies  recommended  above,  but  occasionally  a  more  active 
purgative  effect  may  be  needed.  Since  the  portion  of  intestine  which 
is  chiefly  implicated  in  ordinary  forms  of  constipation  is  the  colon,  it  is 
evident  that,  if  it  be  necessary  to  employ  frequently  any  of  the  active 
purgatives  of  the  pharmacopoeia,  such  should  be  selected  as  ])roduce 
little  or  no  irritation  of  the  long  tract  of  the  small  intestines,  Avhile  they 
stimulate  the  function  of  the  colon.  The  aloetic  preparations  are  pre- 
ferable for  this  purpose,  as  the  tincture  of  aloeS  and  myrrh,  or  the 
simple  tincture  of  aloes,  which  may  be  given  in  dose  of  part  of  a  tea- 
spoonful in  a  convenient  syrup,  or  in  coffee  or  milk. 


INTESTINAL    WORMS.  765 


CHAPTER  XI. 

INTESTINAL  WORMS. 

The  belief  has  been  prevalent  in  the  profession  in  former  times,  and  ig 
now  among  the  people,  that  worms  in  the  intestines  constitute  a  frequent 
disease,  especially  in  children.  As  pathology  and  the  means  of  diag- 
nosticating diseases  are  better  understood,  this  idea  has  been  gradually 
abandoned  by  physicians  and  the  intelligent  portion  of  the  community. 
Still  these  parasites  must  be  considered  an  occasional  cause  of  serious 
derangements,  and,  in  rare  instances,  a  cause  even  of  death.  They 
indeed  often  exist  in  small  number,  without  producing  any  appreciable 
deviation  in  the  individual  from  the  healthy  state  ;  but  the  most  common 
and  best  known  species,  when  they  have  once  effected  a  lodgement  in  the 
intestines  of  man,  ordinarily  grow  and  multiply  so  as  to  produce  symp- 
toms, and  require  medicines  for  their  expulsion. 

So  far  as  is  now  ascertained  by  observations  in  different  countries, 
about  fifty  animal  parasites  make  their  abode  in  man.  It  is  not  im- 
probable that  the  number  will  yet  be  found  'greater  by  observations  in 
distant  uncivilized  countries.  Of  these  fifty,  twenty-one  reside  in  the 
alimentary  canal  (Heller),  several  of  them  being  microscopic.  Of  those 
occupying  the  intestines  only,  the  following  species  are  specially  inter- 
esting to  the  practising  physician,  on  account  of  their  relation — for  the 
most  part  causative — to  certain  pathological  states,  to  wit :  the  ascaris 
lumbricoides,  or  round-worm;  the  oxyuris  vermicularis,  or  thread- 
Avorm  ;  the  bothriocephalus  latus,  and  three  species  of  tfenia,  or  the 
tape-worms,  and  the  trichocephalus  dispar,  or  whip-worm. 

Ascaris  Lumbricoides. — The  round-worm  has  a  dingy  reddish  or 
yellowish-red  color  and  a  cylindrical  form,  tapering  toward  both  ex- 
tremities from  the  point  of  its  greatest  diameter,  which  is  a  little  poste- 
rior to  the  middle.  The  dead  worm  is  paler  than  the  living.  The 
anterior  extremity  is  tipped  with  three  tips,  between  which  and  the 
body  is  a  circular  groove.  Between  these  three  tips  anteriorly  is  the 
aperture  of  the  mouth,  from  which  the  oesophagus  extends  to  the  dis- 
tance of  one-fourth  to  one-third  of  an  inch.  The  intestine,  which  has 
a  light  brownish  color,  extends  from  the  oesophagus  to  near  the  poste- 
rior extremity  of  the  animal,  where  it  terminates  in  the  anus.  The 
females  are  in  numerical  excess  of  the  males,  and  their  size  is  also 
greater.  The  shape  of  the  wovui  is  like  that  of  the  common  earth- 
worm, from  which  it  derives  the  name  linnbricus,  but  it  is  somewhat 
more  pointed  and  its  color  paler  red.  The  tail  of  the  male  worm  is 
curved  like  a  hook,  while  that  of  the  female  is  straight. 

The  total  number  of  eggs  contained  in  a  fully  developed  female  has 
been  estimated  at  sixty  millions.  The  eggs  when  innnature  are  conical, 
and  arc  attached  to  a  longitudinal  band ;  when  mature  they  are  oval, 


766  INTESTINAL    WORMS. 

with  dark  granular  contents  and  a  strong  double  shell,  and  their  aiam- 
eter  is  about  3-^  of  an  inch.  They  are  expelled  in  countless  numbers 
with  the  feces,  and  at  the  time  of  expulsion  are  surrounded  by  an  albu- 
minous coating  stained  with  bile.  Their  vitality  is  retained  under 
apparenth'^  very  unfavorable  circumstances,  even  for  years.  They 
hatch  after  they  have  been  repeatedly  frozen  or  desiccated. 

The  ascaris  lumbricoides  inhabits  the  small  intestines,  Avhere  it  is 
rapidly  developed  from  the  embryonic  state.  The  remark  made  by 
Heller,  that  when  found  in  the  colon  it  is  always  dead,  cannot  be  true, 
for  many  live  worms  are  expelled  in  the  stools. 

The  round-worm,  more  than  all  other  intestinal  worms,  is  inclined 
to  wander  away  from  its  usual  abiding- place,  namely,  ti-om  the  jejunum 
and  ileum,  producing  symptoms  of  more  or  less  gravity,  referable  to 
the  part  over  which  it  crawls.  It  occasionally  enters  the  stomach, 
from  which  it  is  vomited,  or  it  ascends  the  oesophagus  into  the  fauces, 
from  which  it  is  soon  removed  by  the  efforts  of  the  individual.  Cases 
are  on  record,  one  of  Avhich  Andral  witnessed,  in  Avhich  the  worm  en- 
tered the  larynx,  producing  suffocation  and  speedy  death.  Mr.  Ton- 
nelle  also  witnessed  such  a  case.  A  child,  nine  years  old,  was  suddenly 
seized  with  great  difficulty  of  respiration  and  pain  in  the  upper  part  of 
the  chest.  A  careful  examination  of  the  thorax  gave  a  negative  result. 
Death  occurred  in  from  twelve  to  fifteen  hours,  and  at  the  post-mortem 
examination  a  lumbricus  was  found  filling  the  cavity  of  the  larvnx.  M. 
Blandin,  also,  witnessed  a  case,  when  interne  of  the  Hopital  des  En- 
fants.  An  infant  was  suffocated  by  one  of  these  Avorms,  which  had 
penetrated  as  far  as  the  right  bronchus.  Very  rarely  they  crawl  from 
the  fauces  into  the  nasal  passages.  This  worm  is  so  strong  and  active 
that  there  is  no  recess  or  reflexion  of  the  mucous  membrane  of  the 
digestive  apparatus  which  it  could  possibly  penetrate,  in  which  it  has 
not  been  found.  It  has  been  discovered  in  the  appendix  vermiformis, 
in  the  pancreatic  duct,  in  the  common  bile-duct,  and  even  in  the  gall- 
bladder. The  number  of  these  worms  found  in  the  intestines  is  very 
various.  There  may  be  only  one,  or  the  number  may  be  incredibly 
large. 

Thus,  Barrier  relates  the  case  of  an  infant  thirty  months  old,  who 
died  in  Ilopital  Necker.  It  was  believed  to  be  tubercular.  Numerous 
tumors,  which  could  be  felt  in  the  abdomen,  were  supposed  to  be  tuber- 
cular masses.  On  making  the  post-mortem  examination,  the  mesen- 
teric glands  were  found  healthy,  but  the  intestines  throughout  their 
entire  extent  were  filled  with  lumbrici.  The  masses  which,  during  life, 
were  supposed  to  be  tubercular  glands,  were  found  to  consist  of  worms. 
The  cfecum,  especially,  was  greatly  distended  by  them.  The  inter- 
twining or  collection  m  balls  of  these  worms  constitutes,  indeed,  one  of 
the  chief  dangers,  as  it  renders  them  so  much  the  more  difficult  of 
expulsion. 

The  round  worm  possesses  no  organs  of  penetration  ;  still,  if  the 
Intestine  be  weakened  by  disease,  especially  by  ulceration,  it  may,  by 
pressure  with  its  head,  force  an  opening,  through  which  it  escapes  into 
the  cavity  of  the  abdomen,  causing  peritonitis  and  death.     This  worm 


INTE3TIXAL    WORMS.  767 

is  commonly  found,  whether  single  or  in  masses,  surrounded  bj  mucus, 
which  serves  as  a  partial  protection  to  the  intestines. 

The  portion  of  the  mucous  membrane  in  contact  with  lumbrici  is 
often  found  inflamed,  either  from  movements  of  the  worm,  or  from 
pressure  of  a  mass  of  worms,  or  even  of  a  single  worm  in  a  confined 
position,  as  the  appendix  vermiformis.  This  inflammation,  contmuing 
and  increasing,  may  end  in  ulceration,  and  thus  a  weakened  spot  be 
produced,  which  may  be  ruptured  by  simple  pressure  of  the  mouth  of 
the  worm.  In  this  way  are  to  be  explained  those  apparent  cases  of 
perforation  which  have  led  some  observers  to  believe  that  lumbrici  have 
actually  the  power  of  penetrating  the  healthy  coats  of  the  intestines. 
The  perforation  is  obviously  most  liable  to  occur  in  those  who  have  been 
enfeebled,  and  whose  tissues  have  been  rendered  less  firm  and  resistino; 
by  antecedent  disease,  as  by  typhoid  fever. 

M.  Guersant  describes  a  case  in  which  the  appendix  vermiformis 
contained  an  ulcerated  opening,  tlirough  which  two  round-worms  had 
partly  passed  into  the  abdominal  cavity,  producing  fatal  perityphlitis. 
The  effect  of  their  impaction  in  this  narrow  cul-de-sac  was  much  like 
that  of  a  bean  or  seed  lodged  in  the  same  situation. 

The  ascaris  lumbricoides  has  occasionally  been  found  in  the  most 
remarkable  locations,  namely,  in  abscesses  lying  without  the  intestines. 
They  have  been  known  to  eftect  a  lodgement  in  the  liver,  and  produce  an 
abscess  there,  no  doubt  by  crawling  up  and  distending  a  bile-duct. 
Their  lodgement  in  other  viscera,  which  havQ,  no  pervious  connections 
with  the  intestinal  tract,  is  probably  accomplished  through  fistulous 
openings  produced  by  inflammation  which  they  had  no  part  in  causing, 
as,  for  example,  in  the  bladder  and  kidneys,  of  which  there  are  well- 
autlienticated  cases.  Worm  cysts  in  the  abflominal  walls  have  been 
found  to  occur  in  most  instances  in  the  usual  site  of  hernias,  namely,  at 
the  umbilicus  in  children,  and  in  the  inguinal  region  in  adults.  It  is 
presumed,  therefore,  that  the  worms  had  entered  hernial  protrusions, 
from  which  they  had  passed  by  ulceration  into  the  abdominal  walls,  and 
had  there  become  encapsulated. 

The  oxijurh  vermicularis,  or  thread-worm,  so  called  from  its  resem- 
blance to  pieces  of  ordinary  wliite  sewing  thread,  is  also  frequent  in 
childhood,  and  not  infrequent  in  the  adult.  The  length  of  the  male 
oxyuris  is  from  one-sixth  to  one-fifth  of  an  inch ;  that  of  the  female 
from  one-third  to  one-half  an  inch.  The  posterior  extremit}''  of  the 
male  is  bhint,  and  is  curved,  or  rolled  up,  toward  its  abdomen;  that 
of  the  female  is  slender  and  pointed  like  an  awl. 

The  head  of  this  worm  is  rehitively  broad,  from  an  unusual  thickness 
or  fulness  of  the  cuticle,  and  the  mouth,  surrounded  by  "  three  nodular 
lips,"  is  situated  in  the  centre  of  the  extremity.  The  oesophagus  ex- 
tends backward  from  the  mouth,  gradually  growing  larger,  like  the  seg- 
ment of  a  long  and  narrow  cone,  and  ending  in  a  globular  enlargement, 
which  has  been  designated  the  |)liarynx.  From  the  pharynx  the  intes- 
tine runs  in  nearly  a  straight  line  through  the  worm. 

The  eggs  are  numerous,  so  completely  filling  the  interior  of  the  female 
as  to  conceal  the  organs  from  view.  They  are  flattened  on  one  side,  but 
are  rounded  or  convex  on  other  parts  of  their  circumference.     One  end 


768  INTESTINAL    WORMS. 

is  more  pointed  than  the  other,  as  in  the  eggs  of  birds.  Certain  of  the 
eggs  in  tlie  mature  female  are  seen  to  be  undergoing  segmentation  pre- 
paratory to  hatching,  -while  others  more  advanced  contain  tadpole- 
shaped  embryos,  and  others  still  contain  worm-shaped  embi'yos,  either 
lying  Avithin  the  shells  or  protruding  from  them.  The  hatching  and 
growth  of  this  worm,  -which  have  been  observed  under  the  microscope, 
are  very  rapid  under  favoral)le  circumstances.  "I  once,"  says  Heller, 
"  saw  the  metamorphosis  from  the  tadpole-shaped  embr^'o  to  the  Avorm- 
shaped  embryo  completed  in  about  one  hour,"  but  the  usual  time  is 
lono-er.  Leuckhart  saw  oxvurides,  one-fourth  of  an  inch  in  length, 
fourteen  days  after  the  eggs  had  been  swalloAved. 

Oxyurides  may  be  developed  so  rapidly  from  eggs  SAvalloAved  in  the 
ingesta,  that  they  attain  nearly  or  quite  their  full  growth  Avhilo  still  in 
the  small  intestines,  so  that,  although  their  chosen  residence  is  in  the 
large  intestines,  some  of  them  are  not  infrequently  found  in  the  ileum, 
and  even  in  the  jejunum,  of  full  size  and  active.  The  part  of  the  intes- 
tinal tract  Avhich  tlie  oxyurides  prefer,  and  in  Avhich  the  largest  colony 
of  them  reside,  is  the  cfecum  and  appendix  vei-miformis,  and  not  in  the 
rectum,  as  stated  in  most  of  the  books,  and  in  this  situation,  Avhere  they 
have  been  little  disturbed,  their  hal)its  and  the  relative  proportion  of  the 
sexes  can  be  best  observed.  But  they  are  ordinarily  found  both  in  the 
cnecum  and  rectum  in  the  same  individual,  and,  indeed,  upon  all  parts 
of  the  intervening  surface  of  the  colon. 

The  number  of  oxyurides  in  the  individual  varies  greatly.  They  are 
occasionally  so  numerous  upon  the  intestinal  surface  that  they  resemble 
fur,  and  Avhen  they  are  so  abundant  they  are  commonly  found  above  the 
ileo-cfecal  valve  as  Avell  as  beloAV  it.  The  males  are  smaller  and  appar- 
ently more  fragile  and  perishable  than  the  female.  Therefore  in  the 
rectum  and  other  exposed  situations,  there  is  a  numerical  excess  of  the 
females ;  but  in  reflexions  of  the  intestines,  Avhcre  they  are  securely 
lodged,  as  in  the  appendix  vermiformis,  no  marked  difference  has  been 
observed  in  the  relative  number  of  the  two  sexes.  Since  the  males  are 
more  delicate,  transparent,  and  smaller  than  the  females,  they  are  more 
likely  to  be  overlooked  in  a  hasty  post-mortem  examination. 

The  term  tape-tvorm  is  applied  to  several  species  of  the  taenia,  and  to 
at  least  tAvo  species  of  the  bothriocephalus,  but  all  except  four,  to  Avit, 
the  ti^nia  solium,  taenia  saginata  or  medio-canellata,  taenia  elliptica  or 
cucumerina,  and  the  bothriocephalus  latus,  are  rare  in  Europe  and 
North  America,  and  are  therefore  of  little  interest  to  the  practising 
physician. 

The  tape-Avorm  is  an  hermaphrodite,  each  segment  containing  the  tAvo 
sexual  organs.  The  head,  or  scolex,  is  small,  about  the  size  of  a  pin's 
head,  and  segment  after  segment  is  produced  by  a  budding  process  from 
the  head.  The  segments  arc  attached  to  each  other  at  their  extremities, 
and  each  segment  as  it  becomes  further  and  further  removed  from  the 
head,  by  the  formation  of  ncAV  intervening  segments  at  the  upper  end 
of  the  chain,  becomes  also  larger  and  more  matured.  The  oldest  seg- 
ments having  attained  their  full  groAvth,  are  detached,  and  have  an  in- 
dependent existence.  A  separation  of  the  chain  of  segments  at  any 
point  does  not  compromise  the  life  of  the  parasite.     If  only  the  head 


INTE3TIXAL    WORMS.  769 

remain  uninjured  the  segmentation  continues  from  it,  and  in  time  the 
former  number  of  segments  and  former  length  of  the  chain  are  restored. 
This  worm  resides  in  the  small  intestines,  the  larger  species  sometimes 
extending  from  the  upper  part  of  the  jejunum  to  near  the  ileo  ciecal 
valve. 

The  tcenia  solium  is  developed  from  an  embryo,  known  as  the  cysti- 
cercus  celluloste,  contained  in  the  muscles  of  the  hog.  It  has  also  been 
found  in  some  other  animals,  as  the  dog,  deer,  and  polar  bear.  It  is  a 
vesicle,  about  the  size  of  a  pea  or  small  bean,  having  a  delicate  cell-wall, 
and  is  nearly  spherical,  except  as  its  shape  is  changed  by  compression 
between  the  muscular  fibres.  At  one  point  of  the  cell-wall  is  a  depres- 
sion, attached  to  the  inner  surface  of  which,  and  lying  within  the  cyst, 
is  a  whitish,  pear-shaped,  solid  body,  which  is  the  head  of  the  cysti- 
cercus,  and  is  identical  in  ap]>earance  and  character  with  the  head  of 
the  tj^enia  solium  turned  inside  out.  Many  experiments  have  shown 
the  close  relationship  of  the  cysticercus  and  tieaia  solium,  that  they  are 
two  forms  of  existence  of  the  same  parasite.  Segments  of  the  taenia 
solium  have  been  repeatedly  fed  to  pigs,  and  the  cysticercus  produced 
in  their  muscles,  though  jn  what  way  the  ovum  or  embryo  passes  from 
the  stomach  to  the  muscles  is  not  known.  On  the  other  hand,  swine 
flesh  containing  cysticerci  has  been  fed  to  animals  who  were  soon  after 
killeil,  when  the  taenia  was  found  in  their  intestines.  It  is  evident  that 
this  parasite  occurs  only  in  those  who  eat  swine  ilesh,  as  sausages,  either 
raw  or  but  slightly  cooked. 

The  head  of  this  species  of  tnenia,  which  is  about  the  size  of  a  small 
pin's  head,  has  at  the  top  a  conical  protuberance,  upon  which  is  a 
corona  of  booklets,  arranged  in  two  circles,  the  booklets  of  the  outer 
circle  being  smaller  than  those  of  tiie  inner.  The  projecting  points, 
however,  of  the  two  rows  fall  together,  forming  one  circle.  The  hook- 
lets  are  inserted  into  depressions  in  the  head,  and  many  of  them  have 
fallen  out  in  most  specimens  which  we  have  an  opportunity  of  exam- 
ining. The  depressions  in  which  the  booklets  are  lodged  are  often  dark 
from  pigmentation.  Back  of  the  circle  of  hooks  are  four  sucking  disks, 
which  the  worm  is  able  to  protrude  and  move  freely.  When  protruded 
they  appear  as  small  tubercles  w^ith  slender  pedicles.  The  neck,  which 
is  slender  and  about  one  inch  in  length,  shows  markings  from  com- 
men3ing  segmentation,  and  it  is  succeeded  by  very  small  and  delicate 
segments,  which  gradually  increase  in  size  as  the  distance  from  the  heaj 
increases. 

The  jnature  segments  (proglottides)  vary  in  size  accordingly  as  they 
are  in  a  state  of  contraction  or  relaxation.  When  relaxed,  their  length 
is  about  half  an  inch  and  breadth  one-quarter  of  an  inch.  The  genital 
organs  are  situated  on  the  margin  of  each  segment,  a  little  posterior  to 
the  midille,  and  there  is  an  alternation  in  their  locatinn  between  the 
right  and  left  margins  in  the  chain  of  segments.  The  uterus  lies  in  the 
centre  of  the  segment,  forming  a  longitudinal  straight  line.  From 
seven  to  twelve  branches  are  given  off  from  each  side  of  the  uterus,  and 
these  divide  and  subdivide  like  the  branches  of  a  tree.  The  male  genital 
organs  lie  in  the  same  aperture  or  pore  in  the  margin  of  the  segment, 
with  which  the  uterus  and  ovaries  connect. 

■49 


770  INTESTINAL    WORMS. 

The  eggs  of  the  taenia  solium  are  globular,  with  a  diameter  of  about 
yi-^tli  of  an  inch,  and  with  thick  shells,  which  are  striated  like  Mosaic 
work  bv  lines  which  cross  each  other.  It  is  estimated  that  not  less  than 
50,000,000  eggs  are  contained  in  all  the  segments  of  a  matured  tpenia. 

This  parasite  is  very  liable  to  abnormal  development.  In  some  in- 
stances two  or  more  segments  are  fused  together,  and  often  they  are 
stunted  in  their  growth,  or  they  contain  holes,  fissures,  and  Haws,  either 
from  their  original  development,  or  produced  by  rupture  of  the  dis- 
tended uterus.  Again,  rarelv  two  t;«nia  are  blended,  so  that  alonij;  the 
flat  side  of  one  chain  another  is  united  by  the  margin,  so  that  a  section 
of  the  double  pai'asite  resembles  the  Roman  letter  T  or  Y.  The 
nutrition  of  the  segments  is  maintained  through  a  vessel  running  the 
wiiole  length  of  the  worm,  near  each  margin,  and  having  communicating 
branches. 

The  tcenia  saginata,  designated  also  medio-canellata,  is  much  larger, 
stronger,  and  thicker,  both  as  regards  the  head  and  segments,  than  the 
tpenia  solium.  When  fully  matured  it  measures  eighteen  feet.  The 
diameter  of  the  head  is  nearly  one  line  (y|^  inch).  It  is  furnished 
with  four  strong  sucking  disks,  but  it  lacks  the  circlet  of  hooks  which 
characterize  the  taenia  solium.  Instead  of  the  hooks  the  head  is  fur- 
nished with  a  small  frontal  sucking  disk.  The  heads  of  some  specimens 
of  this  worm  are  free  from  pigment,  ])ut  other  specimens  present  various 
shades  of  pigmentation — from  a  slight  staining  to  a  jet  black  color. 
The  neck  is  short,  and  very  near  the  head  are  markings  which  indicate 
commencing  segmentation.  The  matured  segments  vary  in  measure- 
ment when  relaxed — from  a  length  of  eight  lines  and  breadth  of  two 
lines,  to  a  length  of  nine  lines  and  breadth  of  three  lines.  As  in  the 
taenia  solium,  the  genital  pores  are  situated  on  the  margins  of  tlie  seg- 
ments, varying  irregularly  from  side  to  side,  and  the  uterus  has  lateral 
branches,  Avhich  divide  dichotomously.  There  is  but  little  difference 
in  the  sexual  apparatus  of  the  taenia  solium  and  taenia  saginata,  but 
the  esffrs  of  the  latter  are  somewhat  larger  than  those  of  the  former, 
and  are  oval. 

The  development  of  the  taenia  saginata  is  sometimes  irregular,  pro- 
ducing monstrosities,  as  in  the  taenia  solium.  The  embryos  of  this 
parasite  occur  chiefly  in  the  muscles  of  ruminating  animals,  as  the  ox, 
sheep,  goat,  etc.,  and  therefore  its  presence  in  man  is  attributable  to 
the  use  of  the  flesh  of  these  animals,  either  slightly  cooked  or  raw.  The 
cysticercus  of  this  species  appears  to  be  less  tenacious  of  life  than  that 
of  the  tiTsnia  solium,  and  when  it  perishes  it  becomes  changed  into  a 
greenish-yellow  ])ulp,  surrounded  by  the  capsule,  and  imbedded  in  the 
muscular  or  other  tissue  where  it  had  lodged. 

It  is  easy  to  distinguish  this  worm  from  the  taenia  solium  if  the  head 
be  found,  by  its  larger  size,  the  larger  size  of  its  sucking  disks,  and  the 
absence  of  the  circle  of  hooks.  The  segments  are  distinguished  by 
their  greater  size,  and  the  greater  number,  and  the  dichotomous  division 
of  the  branches  of  the  uterus.  This  species  occurs  over  a  much  greater 
area  of  the  earth's  surface  than  the  taenia  solium. 

The  tfEnia  clliptica  or  cucumen'na  is  a  more  delicate  worm  than  the 
preceding  species,  measuring,  when  fully  grown,  from  seven  to  ten  or 


INTESTINAL    WORMS,  771 

eleven  inches  in  length.  Upon  its  head  is  a  rostellum  or  beak,  which 
the  worm  is  able  to  thrust  forward,  and  on  which  are  about  sixty  hooks, 
irref'ularly  arranged.  The  anterior  portion  of  the  parasite  is  very  deli- 
cate, like  a  thread,  and  its  segments  are  small,  but,  as  in  the  other 
species,  they  become  larger  as  their  distance  from  the  head  increases. 
The  matured  segments  which  have  a  reddish-white  color  are  readily  de- 
tached, and  when  separated  they  move  about  actively.  This  tasnia  is 
also  an  hermaphrodite,  and  a  genital  pore  containing  a  double  set  of 
genital  organs  is  located  on  each  margin  of  the  segment.  The  ti^nia 
elliptica  inhabits  the  small  intestines  of  the  dog  and  cat,  and  many  chil- 
dren in  different  localities  have  been  affected  with  it. 

TIeller  states  that  the  segments  of  another  and  rare  species  of  taenia, 
which  were  expelled  from  a  child  of  nineteen  months,  are  preserved  in 
the  Museum  of  Pathological  Anatomy  in  Boston.  Nearly  in  the  mid- 
dle of  the  posterior  half  of  each  segment,  is  a  yellow  spot,  namely,  the 
receptaculum.  full  of  ova,  and,  therefore,  the  name  flavo-punctata  has 
been  applieil  to  this  worm.  Little  is  known  in  regard  to  the  ttenia  nana 
and  tienia  Madagascariensis,  since  they  occur  in  distant  countries. 

The  bothriocephabis  latus  is  the  largest  of  the  tape-worms,  attaining 
the  length  of  15  to  24  feet.  It  is  one  of  the  most  important  of  the  in- 
testinal parasites.  The  head  has  an  almond-shape  or  the  shape  of  an 
elongateil  and  somewhat  flattened  globe,  its  length  being  about  one  line, 
and  its  diameter  from  one-third  to  one-half  a  line.  Running  longitudi- 
nally along  each  flattened  side  of  the  head  is  a  groove  or  fissure,  con- 
taining the  apparatus  of  suction.  Those  segments  which  are  still  in 
the  process  of  growth,  have  a  breadth  three  or  four  times  greater  than 
their  length,  while  the  matured  segments  are  nearly  square.  The  gen- 
ital pore  occurs  in  the  centre  of  one  side  of  the  segment,  and  in  the 
chain  of  segments  all  the  pores  arc  found  on  the  same  side.  A  brownish, 
rosette-shaped  spot  is  observed  at  the  site  of  each  ripe  pore  produced  by 
the  convolutions  of  the  uterus,  and  the  numerous  eggs  which  this  organ 
contains. 

The  egg,  which  is  oval,  lias  a  thin  sliell,  a  light  brown  color,  and  at 
one  end  of  it  is  a  lid  or  o])erculum,  which  is  separated  from  the  rest  of 
the  egg  by  a  well-defined  line.  At  the  hatching  an  embryo,  provided 
with  six  hooks,  escapes  from  the  lid.  When  it  has  separated  from  the 
egg  it  is  provided  with  an  albuminous  covering,  from  which  cilia  radiate 
ill  all  directions,  by  the  movement  of  which  it  is  propelled.  After  a  few 
(lavs  this  covering  is  lost,  and  the  embryo  now  moves  about  by  amoeboid 
extension  and  contraction.  It  is  believed  that  in  this  embryonic  state  it 
enters  an  aquatic  animal,  a  mollusk  or  fish,  where  it  undergoes  further 
development,  and  from  which  it  is  received  into  the  stomach  in  the  food. 

The  bothriocephalus  occurs  not  only  in  man,  but  also  in  some  of  the 
domestic  animals  which  esit  fish,  as  tlie  dog.  This  parasite  is  believed 
to  be  rare  outside  of  Europe,  and  in  Europe  it  is  chiefly  met  in  countries 
bordering  on  inlaml  lakes  and  seas. 

The  trichocephalas  disp'tr  is  comparatively  unimportant  to  the  phy- 
sician, since  it  is  uncertain  whether  it  materially  impairs  the  health  or 
produces  symptoms.  It  inhabits  the  caecum,  but  in  rare  instances  it  has 
been  found  in  the  ileum  and  appendix  vermiformis.     The  number  of 


/72  INTESTINAL    WORMS. 

these  parasites  is  usually  small,  but  as  many  as  seventy  to  one  hundred 
have  been  observed  in  the  intestine  of  the  adult. 

The  trichocephalus  dispar  occurs  also  in  the  monkey,  and  a  very 
similar,  if  not  identical,  worm  has  been  found  in  the  pig.  It  is  not  fre- 
quent in  children,  and  it  has  not  been  observed  in  very  young  children. 
It  occurs  in  man  in  every  part  of  the  globe,  and  in  some  countries,  as 
Egypt,  Nubia,  and  Syria,  it  is  said  to  be  very  common.  This  worm, 
which  is  also  sometimes  designated  the  Avhip-worm  from  its  shape,  attains 
the  length  of  one  and  a  half  to  two  inches,  the  female  being  longer  than 
the  male.  Its  anterior  two-thirdS  are  thin,  delicate,  and  flexible,  like  a 
small  thread.  The  posterior  one-third,  which  contains  the  generative 
organs  and  intestinal  canal,  is  considerably  thicker,  and  it  ends  abruptly. 
On  the  under  surface,  extending  nearly  the  whole  length  of  the  body, 
is  a  longitudinal  band,  tlie  Avidth  of  which  is  about  one-tbird  the  cir- 
cumference of  the  body.  In  the  female,  the  posterior  or  thick  portion 
of  the  worm  is  slightly  bent  or  curved  like  the  stock  of  a  hunting-whip, 
while  that  of  the  male  is  rolled  in  the  spiral  form.  The  digestive  tube 
consists  of  an  oesophagus,  which  extends  through  the  anterior  threaddike 
part,  and  the  stomach  and  rectum  which  lie  in  the  posterior  thick 
division.  The  genitals  of  the  female  lie  in  the  commencement  of  the 
thick  portion,  and  the  uterus,  when  distended  with  eggs,  occupies  nearly 
the  whole  of  this  section.  In  the  male,  the  pore,  which  contains  the 
genitals,  lies  in  the  posterior  extremity  of  tlie  thick  part,  where  it  forms 
a  cloaca  with  the  termination  of  the  intestinal  canal.  The  eggs,  which 
are  numerous,  are  oval,  brownish,  and  Avith  a  glistening  protuberance  at 
each  extremity,  giving  them  the  shape  of  a  lemon.  They  have  great 
vitality,  hatching  after  repeated  desiccation  and  freezing.  Their  de- 
velopment from  the  egg  is  slow.  It  is  believed  that  the  trichocephalus 
is  produced  directly  from  the  egg,  which  has  lodged  in  the  intestine, 
and,  therefore,  does  not  have  or  require  an  intermediate  stage  of  prep- 
aration in  another  animal.  This  parasite  resides  in  the  cnecum,  but 
when  many  are  present,  some  are  found  in  the  ascending  colon,  and 
occasionally  a  few  are  obsei'ved  in  the  small  intestine. 

The  taenia  is  rare  in  early  life,  but  it  now  and  then  occurs  in  young 
children.  I  have  met  cases  in  this  city  under  the  age  of  five  years. 
Rosen  and  Brerascr  report  cases  between  the  ages  of  six  and  eleven 
years,  and  Ilufeland  one  at  the  age  of  six  months.  Wawruch  collected 
206  observations  of  t?enia,  in  22  of  Avhich  the  age  was  less  than  fifteen 
years;  the  youngest  was  a  girl  of  three  years.  A  most  remarkable  case 
of  taenia  is  reported  in  the  Gfazette  Medicale  of  Paris  in  1837.  M. 
Muller  was  called  to  treat  a  foster  child  five  days  old  for  slight  consti- 
pation. The  bowels  were  evacuated  by  the  use  of  rhubarb,  manna, 
and  a  few  grains  of  salt,  and  in  the  excrement  a  foot  and  a  half  of 
taenia  were  discovered.  This  Avorm  had  evidently  existed  during  the 
foetal  life  of  the  infant. 

A  similar  case  Avas  treated  by  Prof.  Skene,  in  the  Long  Island  Hos- 
pital, in  September,  1871,  and  reported  by  Dr.  Armor.'  The  infant 
was  born  September  3d,  of  a  hearty  Irish  servant  girl.      On  the  7th  it 

'  New  York  Medical  Journal. 


INTESTINAL    WORMS.  773 

refused  to  nurse,  and  was  observed  to  have  a  mild  form  of  tetanus.  On 
the  8th  small  doses  of  calomel  having  been  given,  followed  by  castor 
oil,  two  segments  of  a  taenia  solium  were  passed  from  the  bowels,  and 
on  subsequent  days  ten  more  segments,  after  which  the  tetanus  ceased. 
The  remedies  employed  after  September  8th  were  the  oil  of  male  fern 
and  turpentine.  The  mother,  who  had  presented  no  symptoms  of 
tiienia,  was  ordered  an  emulsion  of  pumpkin  seeds,  which  "  she  fiiith- 
fully  took  for  twenty-four  hours,  at  the  end  of  which  she  passed  over 
seventy  segments  of  ttenia."  Tliis  case  is  interesting  as  throwing  light 
on  a  possible  mode  of  the  production  of  tiienia,  quite  different  from  the 
ordinary  and  recognized  mode,  and  also  as  showing  the  causative  rela- 
tion of  intestinal  worms  to  tetanus  infantum. 

Causes. — It  is  obvious  that  intestinal  worms  are  developed  from  eggs 
or  embryo,  which  are  introduced  into  the  stomach  in  the  ingesta.  The 
eggs  of  the  ascaris  lumbricoides  have  been  found  by  Mosler'  in  drinking 
water,  but  it  is  probable  that  in  most  instances  they  are  contained  in 
fruits  and  vegetables  which  are  eaten  raw.  The  eggs  of  the  oxyuris 
vermicularis  are  received  from  some  one  who  is  himself  affected  with 
the  disease.  Both  Zender.and  Heller  state  that  they  have  frequently 
discovered  ripe  eggs  of  this  worm  around  the  nails  of  persons  who  were 
troul)led  with  oxyurides,  a  fact  readily  explained  from  the  itching  which 
they  cause.  If  these  eggs  are  upon  the  fingers  of  the  mother  or  nurse, 
it  is  easy  to  understand  how  they  are  acquired  by  the  child.  We  can 
understand  also  why  this  worm  is  so  common^in  degraded  and  filthy 
families.  In  reference  to  the  etiology  of  the  tape-worm  nothing  need 
be  added  to  what  has  been  stated  above,  and  little  is  known  in  reference 
to  the  manner  in  which  the  eggs  of  the  trichocephalus  are  received. 

Certain  conditions  of  the  intestinal  surface  favor  the  occurrence  of 
worms.  Thus  children  in  advanced  typhoid  fever  are  not  unfrequently 
affected  with  the  ascaris  lumbricoides. 

Symptoms  of  the  Ascaius  Lumbricoides. — These  are  in  part  con- 
stitutional, and  in  part  local,  due  to  the  mechanical  effect  of  the  entozoa 
on  the  coats  of  the  intestines.  Writers,  especially  Rilliet  and  Barthez, 
have  described  with  minuteness  the  symptoms  supposed  to  indicate  lutn- 
brici.  Those  of  a  constitutional  character  are  the  following :  Features 
at  one  time  flushed,  at  another  pallid,  and  in  some  children  of  a  leaden 
hue;  lower  eyelitls  swollen,  and  sometimes  surrounded  by  a  blue  semi- 
circle; thirst,  nausea,  or  even  vomiting;  appetite  diminished  or  aug- 
mented, or  variable;  breath  foul;  papilhe  of  the  tongue  red  and  pro- 
jecting; pulse  accelerated  and  irregular.  Rilliet  and  Barthez  state 
that  they  observed  this  irregularity  of  the  heart's  action  in  a  boy  three 
years  ol<l,  at  the  time  he  was  passing  a  large  number  of  lumbrici.  The 
irregularity  afterward  disappeared.  Acceleration  of  the  pulse  and  in- 
crease in  tem])('rature  are  common  symptoms  of  these  worms,  and  hence 
the  po|)ular  belief  in  a  worm  fever.  This  fever  is  often  remittent  and 
mild,  but  occasionally  it  is  continuous  and  of  a  high  grade. 

The  symptoms  pertaining  to  the  nervous  system  arc  important.  In 
mild  cases  these  may  be  absent,  as  when  there  are  few  lumbrici,  and 

'  Virchow's  Archiv,  1860. 


774  INTESTINAL    WORMS. 

the  child  is  robust,  and  over  the  age  of  five  years,  but  in  severe  cases 
certain  neuropathic  symptoms  are  frequently  present,  such  as  dilatation 
of  the  pupils,  especially  inequality  of  dilatation,  to  which  Munro 
attached  diagnostic  value,  strabismus,  twitching  of  the  muscles,  clonic 
convulsions,  souniolence,  headache,  neuralgic  ])ains,  delirium.  Rarely 
chorea,  deafness,  and  paralysis,  it  is  believed,  may  result.'  Dr. 
Leedom,'  of  Montgomery  County,  Pa.,  relates  the  case  of  a  boy  of  seven 
years,  "who  had  night-blindness  due  to  a  large  number  of  lumbrici  in  the 
intestines.  By  the  employment  of  pinkroot  and  calomel  these  were 
expelled,  and  the  blindness  ceased.  Hypemesthesia  of  the  abdominal 
surface  was  present  in  a  case  which  I  attended,  and  which  subsided  as 
soon  as  the  lumbrici  were  expelled.  Grinding  the  teeth  in  sleep,  and 
picking  the  nostrils,  are  symptoms  to  which  fimilies  attach  groat  value. 
Observations,  however,  show  that,  though  sometimes  due  to  worms,  they 
more  frequently  have  another  cause. 

The  local  symptoms  or  disorders,  in  other  words,  those  having  a 
mechanical  origin,  are  colicky  pains,  experienced  chiefly  in  the  umbilical 
region ;  stools  sometimes  natural ;  in  other  cases  diarrhoea  with  fecal  or 
muco-sanguineous  stools ;  flatulence.  M.  Davaine,  at  a  recent  period, 
made  the  important  discovery  that  the  feces  of  patients  affected  with 
worms  contain  the  ova  of  the  particular  species  present,  in  large  num- 
bers. These  ova,  which  have  been  described  above,  can  be  seen 
through  a  lens  magnifying  150  diameters. 

In  exceptional  cases  there  are  local  symptoms,  due  to  the  presence 
of  these  Avorms  in  unusual  situations,  such  as  a  crawling  sensation  in 
the  oesophagus;  a  sense  of  constriction  in  this  tube  or  the  ])harynx; 
nausea  and  vomiting ;  a  cough,  especially  if  the  worm  have  craAvled  to 
the  upper  part  of  the  oesophagus ;  rarely  the  most  urgent  dyspnoea, 
and  probable  suffocation,  if  a  lumbricus  have  entered  the  larynx.  Ear- 
ache, and  perhaps  convulsions  if  the  worm  have  entered  the  Eustachian 
tube  (Case,  Davaine,  p.  144).  The  most  dangerous  symptoms  arise 
from  the  crawling  of  the  worm  into  narrow  openings 

The  enteritis  and  colitis,  to  which  these  worms  sometimes  give  rise,  are 
ordinarily  mild,  but  in  rare  instances  ulceration  occurs,  Avhich  may  be 
attended  by  profuse  and  even  fatal  hemorrhage.  Occasionally  very 
painful  and  dangerous  constipation  results  from  an  accumulation  of 
Avorms,  in  a  ball  or  mass  too  large  to  be  expelled,  unless  Avith  much 
delay  and  suffering,  preventing  the  passage  of  fecal  matter,  and  pro- 
ducing severe  abdominal  pains.  The  symptoms  in  these  cases  resemble 
closely  those  of  intussusception.  A  marked  example  of  constip.ation 
produced  in  this  Avay  occurred  in  a  f imily  Avith  Avliom  I  am  acfjuaintcd, 
and  Avho  then  resided  in  the  interior  of  this  State.  A  little  girl  of  three 
or  four  years  was  suddenly  affected  Avith  obstinate  constipation.  The 
physicians  prescribed  active  purgatives,  calomel  among  others,  and 
finally  croton  oil,  and  various  injections,  without  relief.  There  Avas 
great  pain  with  distention  of  the  abdomen,  and  death  seemed  inevitable, 

'  Gaz.  dcs  Ilopitaux.  1807. 

*  Amer.  Jouni.  of  Med.  Sci.  for  July,  1867. 


SYMPTOMS.  lib 

when,  after  the  lapse  of  several  days,  a  free  evacuation  occurred,  and  in 
the  stool  was  a  mass  of  worms  firmly  intertwined. 

Children  often  have  lumbrici  without  any  appreciable  impairment  of 
the  general  health,  but  their  presence  may  intensify  the  symptoms  of 
intercurrent  diseases,  and  greatly  increase  the  danger.  Thus  I  recollect 
two  children  of  three  and  three  and  a  half  years,  with  pneumonitis,  who, 
at  the  same  time,  had  lumbrici,  one  passing  in  the  course  of  a  few  days 
thirty  and  the  other  twelve  of  these  entozoa.  Both  presented  well- 
marked  physical  signs  of  pneumonitis,  and,  though  they  recovered,  the 
febrile  movement  and  nervous  symptoms  Were  apparently  aggravated  by 
the  intestinal  affection.  One  had  convulsions  in  the  commencement  of 
the  inflammation,  followed  by  profound  stupor  and  amaurosis,  lasting 
two  or  three  days. 

Often  the  sj^mptoms  due  to  lumbrici  coexist  with  those  of  a  protracted 
and  distinct  intestinal  disease.  Thus,  as  we  have  seen,  the  intestinal 
secretions  of  tyj)hoid  fever  and  of  chronic  diarrha?al  maladies  afford  a 
nidus  for  the  growth  of  worms,  and  accordiny;lv,  at  an  advanced  stui^e  of 
these  diseases,  lumbrici  are  common. 

The  symproms  produced  by  the  oxyuris  vermicularis  are  somewhat 
different.  These  worms  do  not  usually  cause  the  fever,  disturbed  diges- 
tion, the  colicky  pains,  or  the  dangerous  nervous  symptoms  which  arise 
from  the  presence  of  lumbrici.  Nor  do  they,  like  lumbrici,  endanger 
life  by  crawling  into  unusual  situations.  In  one  recent  case,  I  could 
detect  no  other  cause  of  chorea  than  the' presence  of  oxyurides,  and 
eclampsia  has  been  attributed  to  them,  but  such  a  result  is  exceptional, 
if,  indeed,  the  cause  be  rightly  assigned. 

Although  the  caecum  is  the  chosen  abode  of  this  worm,  and  here  more 
than  elsewhere  it  exists  in  its  normal  state,  it  is  not  certain  that  it  pro- 
duces any  appreciable  symptoms  in  this  part  of  the  intestinal  tract. 

The  symptoms  which  render  this  the  most  annoying  of  all  the  intes- 
tinal parasites  are  produced  by  these  oxyurides,  chiefly  the  females, 
which  descend  into  the  rectum,  where  by  their  active  movements  they 
produce  intense  itching.  A  .small  number  of  worms  cause  little  incon- 
venience, but  when  many  are  present  in  the  folds  of  the  rectum  their 
crawling  produces  such  intense  pruritus  that  the  patient  can  with  diffi- 
culty remain  ([uiet.  Usually  this  symptom  is  most  marked  in  the  early 
evening,  when  the  child  is  warm  in  bed.  It  sometimes  causes  onanism 
in  the  girl  as  well  as  boy.  This  syini)tora  may  be  nearly  or  quite  absent 
during  the  day,  but  it  returns  so  regularly  at  night  as  to  resemble  and 
be  mistaken  for  a  periodical  nervous  affection.  So  eminent  a  physician 
as  Cruveilliier  confesses  that  he  has  made  this  mistake  of  dia<iuosis.  In 
the  female  child  the  oxyuris  occasionally  pa.sses  from  the  rectum  to  the 
vulva,  producing  leucorrli(X;a. 

In  many  instances  tapeworms  exist  in  children  as  well  as  adults,  whf> 
thrive  ami  present  no  symptoms,  but  in  other  instances  there  is  more  or 
less  disturbance  of  the  digestive  function,  with  an  uncomfortable  sensa- 
tion in  the  alxlomen.  This  sensation  is  more  noticed  after  fasting,  or 
after  the  use  of  certain  kinds  of  food,  and  it  is  diminisluMl  by  a  full  iuimI. 
Great  hunger  and  a  feeling  of  faintness  are  also  common  according 
to  authorities,  but  I  have  not  particularly  remarked  them  in  children. 


776  IXTESTINAL    WORMS. 

Irregular  action  of  the  bowels,  vomiting,  and  various  nervous  symptoms, 
as  iteliing  of  the  nostrils,  and  anus,  headache,  tinnitus  aurium,  cardialgia, 
numbness,  deafness,  blindness,  etc.,  have  with  more  or  less  correctness 
been  attributed  to  the  tape-worm.  Certainly  such  symptoms  occasionally 
arise  from  this  cause,  for  they  cease  with  the  expulsion  of  the  worm.' 
Intermittent  colicky  pains  in  the  umbilical  region  were  the  only  marked 
symptoms  in  a  child  with  taenia  whom  I  recently  treated.  Since  the 
cysticercus  cellulosfB  is  the  embryonic  form  of  the  tsenia  solium,  it  is 
quite  possible  that  individuals  possessing  the  latter  may  be  infected 
from  its  ova  with  the  former,  so  that  symptoms  which  have  been  attrib- 
uted to  the  intestinal  parasite,  have  sometimes  been  duo  to  the  encysted 
embryo.  We  are  unacquainted  with  the  symptoms  of  the  trichocephalus 
if  any  occur,  and  this  worm  is  very  rare  in  children. 

Diagnosis. — Bremser  long  since  made  the  remark,  and  it  has  been 
repeated  by  most  writers  on  diseases  of  children,  that  there  is  no  sign  or 
symptom  which  affords  positive  proof  of  the  presence  of  intestinal  worms, 
except  the  expulsion  of  one  or  more.  Late  microscopic  investigations 
have  revealed,  however,  a  pathognomonic  sign,  namely  the  presence  of 
ova  in  the  feces,  which  indicates  not  only  the  nature  of  the  disease,  but 
the  species  of  the  worm. 

The  symptoms  and  disorders  produced  by  lumbrici  may  all  occur  from 
other  causes.  Still,  if  several  of  them  be  present,  and  a  careful  examina- 
tion disclose  no  other  cause,  the  presence  of  worms  should  be  suspected, 
provided  that  the  child  be  over  the  age  of  two  years.  The  microscope 
may  then  be  used  for  diagnosis.  A  little  tentative  treatment,  entirely 
safe  to  the  child,  will  also  determine  whether  the  suspicion  be  correct. 
One  or  two  doses  of  medicine,  administered  under  such  circumstances, 
like  the  surgeon's  exploring  needle,  may  reveal  the  nature  of  the  disease, 
and  indicate  the  means  of  cure. 

In  case  of  the  oxyuris  vermicularis,  the  itching  directs  attention  to 
the  anus  as  the  place  of  the  disease,  and  here  the  offending  entozoa 
may  often  be  discovered  by  the  eye. 

Prognosis. — Intestinal  worms  produce  a  fatal  result  in  only  a  small 
proportion  of  cases.  Oxyurides  never  prove  fatal,  unless  in  rare  in- 
stances, through  convulsions.  The  manner  in  which  death  may  be 
produced  by  lumbrici  has  already  been  pointed  out. 

In  general,  when  the  nature  of  the  disease  is  ascertained,  the  worms 
are  readily  expelled  by  treatment,  and  the  patient  restored  to  health. 
Therefore,  if  there  be  no  complicating  disease,  the  prognosis  is  good. 

Treatment. — Much  injury  has  been  done  to  children  by  the  use  of 
anthelmintics  occasionally  employed  by  physicians,  but  oftener  by 
parents  before  the  physician  is  called.  Medicines  of  this  kind  are 
usually  irritants,  and,  in  many  of  those  diseases  which  simulate  the 
verminous  affection,  but  are  distinct  from  it,  there  is  already  an  irri- 
tated if  not  an  inflamed  state  of  the  intestinal  mucous  surface. 

Vermifuges  administered  under  such  circumstances  obviously  do 
harm,  and  in  all  acute  diseases  in  Avhich  they  are  not  required,  even  if 
their  action  be  harmless,  their  employment  is  to  be  regretted,  since  it 

*  MedicD-Cliir.  Rev.,  January,  18G8. 


TREATMENT.  777 

consumes  time  which  is  very  precious.  It  is  thus  that  many  lives  are 
lost  by  the  use  of  anthelmintic  nostrums,  which  are  extensively  adver- 
tised and  which  command  a  ready  sale,  inasmuch  as  the  belief  in  the 
presence  of  worms  as  a  frequent  cause  of  disease  pervades  all  classes. 

A  safe  rule,  followed  by  many  physicians,  and  it  would  be  much 
better  if  it  were  general,  is  not  to  give  anthelmintics  unless  the  child 
have  passed  one  or  more  worms,  or  their  ova  be  found  in  the  feces,  and 
not  then  if  the  sj^mptoms  seem  to  be  referable  to  a  coexisting  disease. 
In  doubtful  cases  in  which  the  symptoms  resemble  those  of  worms,  a 
purgative  dose  of  calomel  or  calomel  and  rhubarb  may  be  employed. 
It  will  generally  bring  away  one  or  more  lumbrici  or  a  mass  of  ascaris 
vermicularis,  if  either  species  of  entozoa  be  present.  This  purgative 
may  be  safely  employed  if  there  be  no  previous  diarrhoea  or  debility. 
If  after  one  or  two  doses  and  a  free  purgation  no  worms  be  passed, 
anthelmintic  remedies  should  not  be  given,  for  it  is  almost  certain  that 
none  exist. 

A  large  number  of  medicines  have,  or  have  had,  a  reputation  as 
anthelmintics.  Santonin,  the  active  principle  of  the  European  worm- 
seed,  is  one  of  the  best;  and  is  much  employed  in  this  country  and  in 
Europe.  It  is  nearly  tasteless  ;  it  may  be  given  in  powder,  spread  on 
bread  with  butter.  It  is  kept  in  shops  in  one  or  two  grain  lozenges, 
with  and  without  calomel.  It  has  the  adv-antage  of  easy  aduiinistra- 
tion,  and  is  destructive  to  both  the  round  and  thread  worm.  M.  Bou- 
chut  considers  it  profji'ablo  to  all  other  remedies  in  the  treatment  of 
the  round-worm.  "  To  cliildron  two  years  of  age  he  aduiinisters  it  in 
doses  of  ten  centigrammes  (1.54  grains),  and  in  patients  above  this  age 
the  quantity  is  increased  by  five  centigrammes  (0.75  grain)  for  every 
additional  year."  He  gives,  in  addition,  occasional  doses  of  calomel  or 
castor  oil.  In  this  country  santonin  is  usually  administered  in  one  to 
three-grain  doses,  two  or  three  times  daily,  with  an  occasional  purga- 
tive. The  j)urgative  is  required  to  aid  not  only  in  the  expulsion  of  the 
worm,  but  also  of  the  ova.  In  overdoses  santonin  causes  vomiting, 
diarrhoea,  and  altered  vision,  so  that  objects  appear  yellow,  but  in 
medicinal  doses  it  produces  no  unpleasant  consequences.  Other  medi- 
cines are  preferalde  if  there  be  svmptoms  of  enteritis.  For  many  years 
the  anthelmintic  most  erai)loyed  in  this  country  was  the  pinkroot,  the 
root  of  the  Spifjeli'i  marilandica,  an  indigenous  plant.  It  was  not  only 
prescribed  by  physicians,  but  employed  by  families  as  a  domestic 
remedy.  It  is  liable  to  cause,  if  the  dose  be  large,  cerebral  symptoms, 
as  vertigo,  dimness  of  sight,  spasm  of  the  facial  muscles,  stupor,  and 
even  convulsions.  These  effects  less  frefpiently  occur  if  the  pinki"oot 
be  given  with  a  purgative,  and  it  has  been  customary  to  administer  it 
in  combination  with  senna  in  an  infusion.  A  half  ounce  of  s|)igelia 
with  an  eqiuil  quantity  of  senna  is  macerated  for  two  houi's  in  a  pint  of 
boiling  Avater,  and  then  strained.  For  a  child  two  or  three  years  old 
the  dose  is  half  an  ounce  to  one  ounce.  So  popular  has  this  vermi- 
fuge been  in  this  country,  that  ])robal)ly  a  majority  of  llie  native-born 
adults  in  the  States  n-collect  the  nauseating  doses  at'  ])inkroi»t  adminis- 
tered by  anxious  parents.     Pharmacy  now  provides  us  with  the  same 


77«  INTESTINAL    WORMS. 

medicine  in  a  more  convenient  and  acceptable  form,  that  of  the  fluid 
extracts : 

R. — Fluid  ext.  spigel f*]. 

Fluid  ext.  senna; f 3ss. — Misce. 

One  leaspoonful  to  a  child  from  three  to  five  years. 

The  officinal  fluid  extract  of  spigelia  and  senna  may  be  given  in  the 
same  dose.  Professor  Procter  recommends  the  addition  of  santonin  to 
this  extract : 

ij  . — Fluid  oxt.  spigel.  et  senna;      .....     f^j. 

tjantonin  ........     gr.  viij. — Misce. 

This  is  probably  the  best  anthelmintic  that  can  be  employed  for  the 
destruction  of  the  round-worm  in  uncomplicated  cases,  and  it  is  also 
very  useful  in  treating  the  ascaris  vermicularis.  Chenopodium  is  also 
a  good  anthelmintic.  It  is  efficient,  and  at  the  same  time  one  of  the 
safest  in  case  the  mucous  membrane  be  inflamed.  If  there  be  abdominal 
tenderness,  with  stools  too  frequent,  and  thin,  or  mucous,  and  tinged 
with  blood,  I  should  prefer  the  clienopodium  to  most  of  the  other  ver- 
mifuges. To  a  child  of  three  years  five  drops  of  the  oil  may  be  given 
three  times  daily.  It  may  be  continued  for  a  longer  period  than  would 
be  safe  for  most  of  the  other  vermifuges.  Twice  a  week,  during  its  use, 
a  mild  purgative  should  be  given,  as  castor  oil,  rhubarb,  or  magnesia, 
unless  the  bowels  are  open.  It  may  be  given  dropped  on  sugar,  or  in  a 
mucilaginous  mixture. 

Dr.  J.  F.  Meigs  says :  "  I  myself  rarely  give  any  other  remedy  than 
wonnsced  oil  in  slight  and  especially  in  doubtfid  cases,  unless  this  has 
already  been  tried  and  failed.  From  my  own  experience,  I  believe  that 
this  remedy  is  all-sufficient  in  a  large  majority  of  the  cases  that  occur 
in  this  city,  as  these  are  almost  always  of  a  mild  character,  and  as  it 
not  only  produces  the  expulsion  of  the  parasites  when  they  exist,  but 
also  acts  beneficially  upon  the  f  )rms  of  digestive  irritation  Avhich  simu- 
late so  closely  the  symptoms  produced  by  worms.  I  am  persuaded, 
indeed,  that  of  all  the  cases  that  have  come  under  my  notice,  in  Avhich 
it  seemed  probable  that  worms  might  be  present,  none  were  expelled  in 
nearly  half,  and  yet  the  signs  of  distui-bed  health  have  passed  away 
under  the  use  of  the  remedy."  ....  "The  following  is  a  very 
good  formula  for  the  administration  of  this  remedy  : 

R. — 01.  chenopodii git.  Ix  vel  fjj. 

V.  a.  acacia;      .         .         .         .         .         .         .         .      g  ij. 

Svrup.  simplie.  .......      .s;j. 

Aq.  cinnarnoni  .......      5  ij. — ^[i>ce. 

"  Give  a  dessertspoonful  three  times  a  day  for  tnree  days,  and  repeat  afier  several 
days." 

In  cases  of  protracted  intestinal  disease  attended  by  an  inci-eased  and 
vitiated  secretion  from  the  mucous  surface,  a  state  which  often  gives 
rise  to  worms,  turpentine  is  one  of  the  best  anthelmintics.  In  fact,  in 
some  of  these  cases  there  is  no  good  substitute  for  it.  For  example,  a 
boy  of  about  ten  years,  attended  by  myself,  October,  1864,  had  reached 
or  nearly  reached   the  fourth  week  of  typhoid  fever,  when  he  passed 


TEEATMENT.  779 

from  his  bowels  a  large  quantity  of  blood.  He  was  previously  emaci- 
ated and  weak,  and  there  had  been,  as  is  usual  in  such  cases,  consider- 
able diarrhoea.  The  hemorrhage  was  attended  with  great  prostration, 
from  which,  however,  he  partially  rallied  by  the  use  of  stimulants.  On 
the  following  day  an  equally  severe  hemorrhage  occurred,  attended 
with  coldness  of  the  face  and  extremities  and  great  feebleness  of  pulse, 
so  that  death  appeared  imuiinent.  Turpentine  was  now  administered 
every  six  hours,  a  few  lumbrici  were  passed,  and  the  case  thenceforth 
progressed  fivorably.  The  mechanical  effect  of  the  lumbrici  on  the 
ulcerated  surface  of  intestine  had  probably  given  rise  to  the  hemor- 
rhage. Turpentine  may  be  given  in  doses  of  from  five  to  ten  minims 
three  times  daily  to  a  child  five  years  old.  Sweetened  milk  or  sugar  in 
powder  is  a  good  vehicle  for  it,  or  it  may  be  given  in  a  mucilaginous 
mixture. 

R. — Spts.  terebinth,  rect.         ......  ^ij. 

Ol.  limonis        ........  gtt.  v. 

Mucil.  gum  acae., 

Syr.  simplic.     ........  afi  ^vj. 

Aq.  anisi 5J-'j- — ^I'sce. 

Dose,  one  teaspoonful  every  six  hours. 

The  following  formula  for  the  employment  of  this  agent  is  recom- 
mended by  Dr.  Condie : 

R. — Mucil.  glim  acac.      .         .         .         .         .         .         •  ^U- 

Sufch.  alb.         .  .  .  .  .  .  .  .  5  X. 

Spir.  aither.  nitr.       .......  ^iij. 

Spin,  terebinth,  rect.         ......  ^lij. 

Magnes.  calcinat.      .......  t^j. 

Aquaj  menthie  .......  3J. — Misce. 

It  is  useless  to  enumerate  the  many  anthelmintic  mixtures  which 
have  been  extolled  from  time  to  time.  Those  mentioned  above  are  the 
least  nauseous,  and  will  rarely  disappoint  the  practitioner.  One  other 
antidote  for  the  round-worm  should  be  mentioned,  as  it  has  been  much 
used  and  is  efficient,  namely,  cowhage.  This  consists  of  the  bristles 
which  cover  the  pods  of  the  MncHna  prurifns,  a  tropical  ]dant.  The 
pods  are  dippetl  in  plain  syrup  of  the  ordinary  consistence,  and  the 
bristles  are  scraped  off"  with  the  syrup.  When  enough  of  the  medicine 
is  added  to  render  the  syrup  of  the  consistence  of  thick  lioney,  it  is 
ready  for  use.  The  dose  is  a  teaspoonful  every  morning  for  three 
days,  after  which  a  cathartic  should  ha  administered.  I  have  never 
prescribed  CDwhage,  although  it  is  not  unrrctjuently  ordered  by  J'hy- 
sicians,  and  a  ])0|)ular  nostrum  consists  chielly  of  it. 

One  a'fected  with  tapeworm  is  obviously  cured  only  when  the  head  of 
the  parasite  is  exj)elled ;  but,  in  the  majority  of  cases  which  I  have  ob- 
serve<l,  the  head  has  not  been  found  in  the  evacuations,  even  Avhen  the 
treatment  had  eff'ected  a  complete  cure,  as  shown  by  the  sub.sccjucnt 
history.  The  chain  of  expelled  segments  connuonly  terminate(l  very 
near  the  head.  This  I  l)elieve  is  the  common  expi-rience  it"  we  trust  the 
friends  of  the  patient  with  the  examination  of  the  stools.  The  physi- 
cian himself  should  search  for  the  W(jrm's  head,  the  evacuations  being 


780  INTESTINAL    WORMS. 

preserved.  The  nurse  should  be  directed  to  add  a  little  carbolic  or 
salicylic  acid,  and  a  sufficient  (juantity  of  water  nearly  to  fill  the  vessel. 
The  liquid  should  not  be  roughly  stirred  with  a  stick,  as  physicians  are 
in  the  habit  of  doing,  since  this  breaks  the  worm  into  small  portions, 
and  renders  the  inspection  more  difficult,  but  it  should  be  shaken  fre- 
quently so  as  to  detach  the  segments  and  head,  if  it  be  present,  from 
the  fecal  matter.  After  it  has  stood  at  least  five  to  ten  minutes,  the 
woim,  which  has  greater  specific  gravity  than  water,  sinks  to  the  bot- 
tom, and  the  upper  part  should  be  poured  off.  This  process  must  be 
repeated  till  the  water  is  nearly  colorless,  after  which  search  should  be 
made  for  the  fragments,  and  the  head,  if  present,  will  be  found. 

Since  entire  expulsion  of  the  tape-worm  is  effected  with  difficulty, 
preparatory  treatment  for  about  forty-eight  hours  should  be  emjdoyed 
before  the  vermifuge  is  administered.  During  this  time  the  patient 
should  take  a  mild  })urgative  once  or  twice,  and  such  food,  in  moderate 
quantity,  should  be  allowed  as  leaves  little  residuum,  as  beef-tea,  milk, 
etc.,  with  some  stimulant,  if  the  patient  feel  exhausted.  There  are 
three  articles  of  food  which  experience  has  shown  to  be  especially  useful 
in  this  preparatory  treatment,  perhaps  from  a  sickening  effect  Avhich 
they  produce  upon  the  worm,  namely,  salt  herrings,  onions,  and  garlic. 
They  may,  therefore,  be  taken  as  food  in  the  twelve  or  eighteen  hours 
preceding  the  employment  of  the  vermifuge,  which  it  is  ordinarily  most 
convenient  to  administer  in  the  morning. 

The  various  tuenicides  recommended  in  the  books  are  probably  all 
more  or  less  efficient,  but  the  one  which  has  given  most  satisfixction  in 
the  Outdoor  Department  at  Bellevue,  where  probably  a  larger  number 
of  these  cases  are  treated  than  in  any  other  place  in  this  country,  is  the 
oil  of  male  fern  ;  but  it  is  found  necessary  to  employ  a  larger  dose  than 
is  recommended  in  some  of  the  books.  For  a  child  of  six  years  the 
dose  employed  is  one  drachm  in  any  convenient  vehicle,  as  the  syrupus 
aurantii  florum.  This  should  bo  followed  in  about  four  hours  by  a  dose 
of  castor  oil,  which  completes  the  treatment.  Heller,  a  high  German 
authority,  recommends  koosso  or  its  active  principle  koossin,  in  the  use 
of  which  I  have  had  no  personal  experience.  The  pumpkin-seed  has 
also  been  employed  at  Bellevue  and  in  other  parts  of  this  city,  but  it 
seems  to  be  less  efficient  than  the  oil  of  the  fern.  If  the  chain  of  seg- 
ments break  near  the  head,  and  the  head  be  not  seen,  it  will  be  necessary 
to  wait  two  or  three  months,  in  order  to  determine  whether  the  cure  is 
complete. 

Since  the  symptoms  produced  by  the  oxyuris  vermicularis  are  refer- 
able chiefly  to  the  rectum,  and  are  caused  by  the  active  movements  of 
the  worm,  the  prompt  and  thorough  use  of  enemata,  which  causes  their 
expulsion,  is  evidently  required.  Enemata  ai'e  more  effectual  if  used 
cool  than  if  Avarm;  and  since  this  worm  inhabits  the  crecnm  as  well  as 
rectum,  large  enemata  given  through  a  long  tube  or  a  large  catheter 
are  more  effectual,  causing  the  expulsion  of  a  larger  number  of  worms 
than  are  expelled  by  small  enemata  employed  in  the  usual  manner. 
Viirious  substances  have  been  used  for  this  purpose, as  lime-water,  table 
salt  in  Avater,  turpentine  in  milk,  decoction  of  aloe,  decoction  of  garlic, 
etc.     lleller  says :   "  Simple  water  would  do  well  for  this  purpose,  for 


G  ASTRO-IXTESTINAL    HEMORRHAGE.  781 

in  a  short  time  it  causes  the  worm  to  swell  up  and  burst ;  but  that  is 
not  altogether  without  an  injurious  effect  on  the  intestinal  mucous 
membrane.  Hence,  Vix  recommends  a  solution  of  castile  soap,  in  dis- 
tilled water,  or  rain-water,  of  the  strength  of  one  to  two  and  a  half 
grains  to  the  ounce.  This  has  no  unpleasant  action  on  the  intestinal 
mucous  membrane,  while  at  the  same  time  it  quickly  destroys  both  the 

worms  and  their  eggs Vix  has  tested  all  the  medicines 

usually  used  in  enemata,  and  has  found  the  above  solution  of  castile 
soap  to  be  the  most  eiTectual."'  The  use  of  the  enema  in  the  evening, 
although  only  a  small  quantity  of  liquid  be  used,  so  as  to  wash  out  the 
rectum,  insures  relief  from  the  itching  and  sleeplessness  during  the 
night. 

But  it  is  undeniable  that  enemata  alone  do  not  effect  a  complete  and 
permanent  cure  in  a  large  proportion  of  cases,  and  lience  those  affected 
with  this  worm  remain  sufferers  for  years,  having  only  a  temporary 
respite,  unless  medicines  be  administered  by  the  mouth.  Those  medi- 
cines Avhich  produce  free  Avatery  evacuations  appear  to  be  the  most 
effectual  in  dislodging  and  expelling  oxyurides,  whose  attachment  to  the 
intestinal  surface  is  not  strong;  therefore  Heller  recommends  the  saline 
purgatives  '"joined  with  copious  draughts  of  water." 


CHAPTER   XIT. 

GASTRO-INTESTINAL  HEMORRHAGE. 

Hemoriuiage  from  the  capillaries  is  more  frequent  in  infancy  than 
at  any  other  period  of  life,  whether  in  consequence  of  the  irreguuirity 
of  the  circulation  and  frequent  congestions  in  the  infant,  or  the  greater 
delicacy  and  feebleness  of  the  minute  vessels  at  this  age.  Hemor- 
rhage, generally  capillary,  from  the  gastro-intestinal  mucous  surface, 
occurs  sufficiently  often  in  the  child,  and  especially  in  the  infant,  to 
render  it  a  disease  of  some  importance.  It  is  more  fre(iuent  the 
younger  the  in<lividual. 

Tliis  hemorrhage  occurs  in  three  distinct  pathological  stages:  first, 
in  the  newborn  infant  from  causes  not  fully  ascertained;  secondly, 
from  a  pathological  state  of  the  blood  or  the  vessels  in  whicli  it  circu- 
lates, and  whicli  is  often  connected  with  purpura  hromorrhagica ; 
thirdly,  from  a  local  cause. 

Fimt  J'arictif. — Tn  41)  cases,  which  I  have  collected  fioni  different 
writers,  the  hemorrhajre  occurred  in  38  under  the  age  of  six  davs,  in  5 
from  six  to  ten  days,  and  in  G  from  ten  to  twenty  days.  Some  authors 
cite  cases  which  occurred  at  the  ago  of  several  weeks,  but  hemorrhage 
into  the  intestines  at  so  late  a  period  cannot  bo  duo  to  any  cause  oper- 


782  G  ASTRO-IXTESTINAL    HEMORKHAGE. 

ating  at  birth,  and  it  is  proper  to  consider  such  as  examples  of  one  of 
the  other  varieties. 

Passive  congestion  of  the  gastro-intestinal  mucous  membrane  is  not 
infrequent  in  the  newborn.  Billard  speaks  of  twenty-five  cases  with- 
out hemorrhage  Avhich  he  has  examined.  This  anatomical  state  of  the 
mucous  membrane  of  the  intestines,  Avhether  occurring  as  a  \r.\Yt  of  a 
general  plethora  or  being  simply  a  local  afiection  with  no  hyper^emia 
of  other  parts,  evidently  requires  only  a  certain  increase  and  hemor- 
rhage results. 

The  cause  of  the  abnormal  congestion  of  the  gastro-intestinal  mucous 
membrane,  so  common  in  the  newborn,  has  been  referred  by  writers  to 
the  previous  health  of  the  parents,  to  circumstances  attending  the  birth, 
especially  to  too  speedy  a  ligature  of  the  cord,  to  irritant  matters  in  the 
intestines,  to  external  violence,  and  to  the  two  opposite  extremes, 
namely,  a  plethoric  and  a  feeble  state.  In  my  opinion,  the  chief  cause, 
in  many  cases,  is  the  tardy  or  incomplete  establishment  of  the  respira- 
tory and  circulatory  functions,  winch  gives  rise  to  congestion  in  the 
cavities  of  the  lieart  and  in  the  lungs,  and,  consequently,  in  the  capil- 
laries throughout  the  system.  Evidently,  this  congestion  is  most  in- 
tense in  the  full-blooded.  Billard  says  of  fifteen  cases  of  intestinal 
hemorrhage  which  he  examined,  most  of  them  were  remarkable  for  the 
plethoric  condition  of  their  bodies  and  the  general  congestion  of  their 
integuments.  Some,  on  the  contrary,  were  pale  and  feeble,  as  is  com- 
mon after  abundant  hemorrhao-e. 

o 

In  two  infants  who  died  soon  after  birth,  and  whose  bodies  I  subse- 
quently examined,  there  was  apparently  a  plethoric  state,  which  ren- 
dered a  fatal  result  more  certain,  if  it  did  not,  indeed,  produce  it.  In 
one  of  these,  in  addition  to  intense  general  congestion,  meningeal  apo- 
plexy had  occurred,  although  the  birth  of  the  child  had  been  easy. 

It  is  not  difficult  to  understand  in  what  way  too  speedy  a  ligature  of 
the  cord  may  be  a  cause  of  capillary  congestion  and  hemori-hage.  At 
the  moment  of  birth,  the  uterus  is  contracted,  the  placenta  compressed, 
and,  if  the  cord  be  now  tied,  more  blood  remains  in  the  vessels  of  the 
infant  than  if  tied  a  little  later.  A  little  later,  in  consequence  of  the 
temporary  cessation  of  uterine  contractions,  and  the  reestablishment  of 
circulation  in  the  infant,  blood  flows  through  the  cord  toward  the  pla- 
centa. The  cord  thus  acts  as  a  safety-valve  to  the  circulation.  Any 
accoucheur  who  will  take  pains  to  witness  the  effect  on  the  cord  of  the 
return  of  circulation,  will  observe  what  I  have  stated.  Too  speedy  a 
ligature  of  the  cord  would  not,  however,  be  sufficient  in  the  majority  of 
cases  to  produce  that  amount  of  plethora  which  gives  rise  to  intestinal 
hemorrhage  without  other  cooperating  causes. 

Tardy  or  incomplete  establishment  of  respiration  and  circulation, 
which  gives  rise  to  intestinal  congestion  and  hemorrhage,  may  be  due 
to  disease  of  the  heart  or  lungs,  as  atelectasis  or  cyanosis,  to  feebleness 
of  the  infant,  or  to  slow  and  difficult  birth.  In  a  large  proportion  of 
cases,  however,  the  birth  is  easy.  Thus,  three  of  five  patients  with 
intestinal  hemorrhage,  who  were  treated  by  M.  Gendrin,  were  born  of 
an  easy  labor,  and  the  same  was  true  of  four  infants  observed  by  M. 
Kiwisch. 


GASTRO-IXTESTIXAL    HEMORRHAGE.  783 

Although  gastro-intestinal  hemon-hage  in  the  neAvborn  apparently 
results  in  certain  instances  from  the  conditions  mentioned  above,  -which 
produce  congestion  of  the  gastro-intestinal  mucous  surface,  there  are 
other  cases  in  ■which  the  cause  must  be  different.  Dr.  Silverman,'  of 
Breslau,  has  recently  published  the  statistics  of  42  cases,  23  of  Avhich 
were  fatal.  In  25  of  these  the  blood  escaped  both  from  the  mouth  and 
anus,  in  10  from  the  anus  alone,  and  in  7  from  the  mouth  alone.  The 
hemorrhage,  in  a  majority  of  the  cases,  began  on  the  second  day  after 
birth,  but  in  11  it  began  on  the  first  day,  and  in  all  prior  to  the  eighth. 
It  is  suggested  that  the  hemorrhage,  in  certain  instances  at  least,  occurs 
from  an  ulcer  in  the  gastro-intestinal  surfoce,  which  is  produced  by  an 
embolus  in  the  umbilical  vein,  or  its  branches,  or  by  suspension  or 
incomplete  establishment  of  the  respiratory  function  in  consequence  of 
accidents  of  birth,  atelectasis,  etc.  Ebstein,  according  to  Silvei'man, 
has  demonstrated  experimentally  that  the  suspension  of  respiration  in 
animals  produces  congestion,  extravasation  of  blood,  ulceration  in  the 
stomach.  From  the  foetal  anatomy,  it  is  evident  that  an  embolus  oc- 
curring in  the  umbilical  vein  near  the  liver,  and  extending  into  the 
branches  of  the  vein,  would  be  likely  to  cause  congestion  of  the  intes- 
tines by  obstructing  the  portal  circulation. 

Dr.  Lederer^  states  that  he  has  treated  eight  newborn  infants  for  this 
disease,  five  of  which  died  from  the  severe  gastric  and  intestinal  hem- 
orrhage, accompanied  also  by  umbilical  hemorrhage.  The  age  of  the 
youngest  was  six  hours.  That  of  the  oldest  eleven  days.  They  were 
all  well  developed,  of  normal  conformation,  and  were  nourished  with 
breast-milk.  In  the  three  who  were  cured,  the  hemorrhage  was 
arrested  in  twenty-four  hours,  but  there  was  for  a  long  time  a  tendency 
to  intestinal  catarrh.  Dr.  Lederer  admits  the  obscurity  of  the  cause, 
but  does  not  think  that  it  was  an  embolism  in  all  the  cases. 

The  second  variety  of  gastro-intestinal  hemorrhage  often  occurs  as  a 
sequel  of  other  and  debilitating  diseases.  I  have  known  it  to  occur  as 
a  sequel  of  measles,  smallpox,  scarlet  fever,  and  in  one  case  of  typhoid 
fever.  One  of  these  patients,  when  apparently  the  period  of  danger 
was  passed,  began  to  lose  blood  from  nearly  all  the  mucous  surfaces, 
from  the  nostrils  and  gums,  as  well  as  intestines,  and  the  case,  Avhich 
but  for  the  hemorrhage  would  doubtless  have  had  a  favorable  issue, 
terminated  fatally  in  less  than  a  week. 

Patients  with  this  variety  of  gastro-intestinal  hemorrhage  sometimes 
present  the  macule  of  purpura,  and  commonly  their  aspect  is  pallid  and 
cachectic.  The  followinsx  Avas  a  fatal  case  of  hemorrhatro  occurrini? 
from  the  ileum,  in  a  mild  form  of  purpura  hemorrhagica. 

Case. — An  infant,  eight  months  old,  of  healthy  parentage,  nursing,  with 
no  previous  sickness,  and  fleshy,  vomited  a  small  quantity  of  blood  on  the 
2oth  of  March,  18(55;  soon  after  it  passed  a  stool  consisting  of  almost  pure 
blood.  On  the  following  day  five  or  six  patches  of  ])urpura  liaMnorrha^nca 
were  observed  on  the  arms  and  le^s.  These  maculic  continued  till  death. 
There  was  no  more  hrematemesis,  but  the  stools,  which  were  from  two  to 

'  Jahr,  fur  Kindeih.,  Sept.  1877.  '  Zeitung  fiir  Kindorli.,  Nov.  1877. 


784:  GASTRO-IXTESTIXAL    HEMORRHAGE. 

four  daily,  consisted  largely  of  blood.     Death  occurred  from  exhaustion 
on  March  olst. 

iSectio  Oidaver. — Head  not  examined  ;  thoracic  origans  healthy,  but 
pale  ;  liver  fatty  ;  stomach,  ujjper  part  of  small  intestines,  and  entire  colon 
of  normal  appearance,  unless  presenting  a  somewhat  lighter  color  than 
the  healthy  intestine  from  deficiency  of  blood ;  mucous  membrane  in  the 
ileum,  to  the  extent  of  several  inches,  inten.<ely  injected  without  thicken- 
ing. The  blood  had  obviously  escaped  from  this  portion  of  the  intestine, 
and  a  moderate  amount  of  this  fluid  was  fouml  in  the  tube  below  the 
point  of  vascuhirity.  This  case  is  interesting  not  (mly  on  account  of  the 
development  of  purpura  htemorrhagica,  but  because  of  the  subsequent 
intestinal  hemorrhage  in  a  nursing  child,  ai^parently  of  healthy  ])arent- 
age,  and  without  previous  sickness. 

In  our  remarks  on  internal  convulsions,  the  case  is  related  of  a 
scrofulous  infant,  Avho,  to  all  appearance  in  lier  ordinary  health,  sud- 
denly became  affected  with  intestinal  hemorrhage  in  connection  with 
external  and  internal  convulsions.  A  point  of  interest  in  this  case  was 
the  relation  of  the  hemorrhage  to  the  neurosis.  In  one  of  the  three 
cases  of  intestinal  liemorrhage  described  by  West,  there  were  also  con- 
vulsions. In  rare  instances  there  is  an  hereditary  hemorrhagic  diathesis 
to  which  the  hemorrhage  is  attributable.  The  late  Prof  Swett^  relates 
the  history  of  a  hemorrhagic  family.  Seventeen  out  of  eighteen  chil- 
dren of  this  f;imily  had  died  of  hemorrhages,  and  the  survivor  had  had 
intestinal  hemorrhage  with  epistaxis. 

In  the  third  variety,  among  the  local  causes  producing  hemorrhage 
may  be  mentioned  ulceration,  as  in  typhoid  fever,  or  in  severe  intestinal 
inflammation,  the  mechanical  effect  of  solid  substances,  lumbrici,  invagi- 
nation, obstruction  to  the  portal  circulation,  polypus  of  the  rectum. 
Occasionally  at  the  post-mortem  examination  of  yourtg  infants  I  have 
found  blood  with  mucus  in  the  duodenum  and  jejunum,  these  portions 
of  the  intestines  being  at  the  same  time  intensely  congested.  In  one 
case  of  protracted  entero-colitis  occurring  in  the  summer  season,  I 
found  many  small  circular  ulcers  in  the  colon,  nearly  all  containing 
points  of  extravasated  blood.  Such  are  the  principal  local  causes  of 
hemorrhage  from  the  bowels.  Ordinary  colitis  may  also  be  considered 
a  cause,  although  the  amount  of  blood  evacuated  in  this  disease  is  com- 
monly small. 

Of  the  three  forms  of  intestinal  liemorrhage  described  above,  that 
arising  from  local  causes  is  most  fre((uent,  while  that  occurring  from  a 
purpuric  or  hemorrhagic  diathesis  is  least  frequent.  In  rare  cases  fatal 
intestinal  hemorrhage  may  occur  in  the  newborn,  and  the  blood  be 
retained  in  the  intestine,  or  if  passed  it  may  so  closely  resemble  the 
meconium  that  its  true  nature  is  not  discovered.  Mr.  Bednar"  relates 
the  following  case:  "On  the  eleventh  d;iy  after  birth  the  boy's  skin 
(then  of  a  pale  yellow  color)  diminisherl  in  warmth,  the  impulse  of  the 
heart  became  dull  and  prolonged,  the  respiratory  murmur  scarcely  per- 
ceptible.    The  child  lay  almost  motionless  and  slumbering.     The  day 

'  Nfw  York  .Journal  of  i\rpclicine  and  Surgery,  July,  1840. 
*  Xmnkheiien  der  Neui^eboruen. 


TREATMENT.  785 

following  the  surface  could  scarcely  be  kept  warm,  and  the  little  patient 
had  to  be  aroused  to  suck.  On  the  twentieth  day  after  birth  it  died. 
The  brain  was  found  to  be  ant^mic,  the  lungs  plethoric,  while  the  blood 
was  effused  into  the  duodenum  and  stomach.  " 

Intestinal  is  more  frequent  than  gastric  hemorrhage,  ami  the  flow, 
except  when  produced  by  a  local  cause,  is  usually  from  the  small  intes- 
tines. The  blood,  unless  it  come  from  a  point  near  the  anus,  as  the 
rectum  or  descending  colon,  is  commonly  dark,  and  sometimes  partially 
decomposed,  emitting  an  offensive  odor.  Admixture  of  the  blood  with 
the  intestinal  secretions  prevents  congulation  of  the  fibrin. 

Gastro-intestinal  hemorrhage  in  itself  produces  few  symptoms  aside 
from  the  prostration  which  attends  all  hemorrhages.  The  disease  Avith 
which  it  is  associated  may  give  rise  to  many  and  severe  symptoms. 

Prognosis. — The  result  in  the  first  and  second  varieties  is  much 
more  unfavorable  than  in  the  third.  Many  newborn  infants  affected 
with  gastro-intestinal  hemorrhage  die,  but  some  recover.  Billard 
attended  fifteen  fatal  cases.  It  is  probable,  however,  that  death  in  the 
first  variety  is  often  due  more  to  soine  coexisting  lesion,  than  to  the  intes- 
tinal hemorrhage.  Meningeal  apoplexy,  and  the  incomplete  establish- 
ment of  the  circulatory  and  respiratory  functions,  may  both  operate  as 
direct  causes  of  death  in  this  variety. 

In  the  second  variety,  also,  a  very  guarded  prognosis  should  be 
given  ;  so  great  a  change  in  the  circulatory  system  as  to  cause  rupture 
of  the  capillaries,  or  transudation  of  blood  in  the  ordinary  course  of  the 
circulation,  is  a  serious  state.  When  this  hemorrhage  occurs  as  a  sequel 
of  the  eruptive  fevers,  or  in  purpura  haemorrhagica,  the  pitient  is  more 
likely  to  die  than  recover. 

In  the  third  form  of  intestinal  hemorrhage,  the  result  depends  on  the 
nature  of  the  cause,  whether  it  be  susceptible  of  removal.  The  majority 
of  cases  in  this  variety  recover. 

Treatment. — Billard  recommends,  as  a  means  of  pre/enting  capil- 
lary congestion  and  hemorrhage  in  the  newborn,  to  allow  a  little  blood 
to  escape  from  the  umbilical  cord  before  its  ligation,  if  the  establish- 
ment of  respiration  and  circulation  be  difficult  or  incomplete.  This 
relieves  the  hyperocmia  of  the  internal  organs  antl  facilitates  the  flow 
of  blood.  After  the  C(jmmencementof  internal  hemorrhage  and  the  aj)- 
pearance  of  bloody  stools,  the  same  may  be  done  if  plethora  be  indicated 
by  the  florid  and  robust  appearance  of  the  infant,  and  the  cord  be  not 
too  much  shrivdled. 

The  treatment  both  therapeutic  and  regimenal,  of  intestinid  hemor- 
rhage, should  vary  according  to  the  age  and  state  of  the  infant,  the  pro- 
fuseness  of  the  hemorrhaire,  and  the  nature  of  the  cause.  Perfect 
quietude,  in  the  recumbent  positioTi,  is  requisite  in  all  severe  cases. 
Derivation  to  the  extremities  should  be  procured  in  the  young  infant, 
by  heated  dry  flannel  or  flannel  wrung  out  of  hot  water;  in  the  older 
infjint,  by  the  same  Avith  the  addition  of  mustard.  The  nursing  infant 
should  remain  at  the  breast,  being  allowed,  perhaps,  in  ad<lifion  to  the 
breast-milk,  a  little  cool  barley  or  gum-water.  Spoon-f('(l  infants  should 
be  given  food  of  the  blandest  ((uality,  in  the  liquid  form  and  cool.  This 
is  the  proper  diet,  whatever  the  age,  in  the  commencement  of  the  hemor- 

60 


786  G ASTRO- INTESTINAL    HEMORRHAGE. 

rhage.  If  there  he  evidence  of  exliuustion,  cool  beef-tea,  or  essence, 
and  alcoholic  stimulants,  are  necessary.  It  has  been  advised,  in  certain 
forms  of  intestinal  hemorrhage,  to  ajiply  leeches  over  the  abdomen  or 
around  the  anus.  This  treatment  ■would,  in  my  opinion,  rarely  be 
useful,  but,  on  the  contrary,  in  most  cases,  injurious.  Hemorrhage 
from  a  mvicous  surface,  which,  when  once  established,  generally  quickly 
relieves  the  local  hypercemia,  and  leeching  will,  unless  very  cautiously 
employed,  promote  the  prostration,  in  which  the  real  danger  in  this 
disease  consists.  On  the  other  hand,  moderate  counter-irritation  over 
the  abdomen  may  be  attended  with  real  benefit  as  a  derivative. 

The  tiierapeutic  treatment  consists  mainly  in  the  use  of  astringents. 
Of  the  mineral  astringents,  acetate  of  lead  and  nitrate  of  silver  have 
been  used,  but  the  li([Uor  ferri  sulisulphatis  is  preferable  to  all  other 
astringents  in  hemorrliage  from  the  stomach  and  upper  part  of  the  small 
intestine,  but  it  is  believed  to  be  decomposed  in  its  passage  through  the 
intestine,  so  that  it  has  less  astringent  or  styptic  effect  in  the  lower  bowel 
than  gallic  acid.  It  may  be  given  to  a  child  five  years  of  age,  in  doses 
of  five  drops,  in  sweetened  water  or  in  mucilage. 

Astringent  enemata  are  sometimes  useful.  M.  Rilliet  treated  a  case 
which  recovered  with  enemata,  each  containing  twelve  grains  of  extract 
of  rhatany,  a  strong  decoction  of  the  same  astringent  being  applied  ex- 
ternally to  the  abdomen.  M.  Bouchut  recommends  "cold  water  exter- 
nally to  the  abdomen,  internally  by  the  mouth,  or  by  enemata  frequently 
repeated.  These  enemata  should  be  composed  of  two  or  three  large 
spoonfuls  only.  They  may  be  rendered  more  active  with  three  grains 
of  tannin,  or  with  seven  grains  of  the  extract  of  rhatany  or  seven  grains 
of  catechu,  or,  lastly,  Avitli  one  grain  of  nitrate  of  silver.  In  this  hitter 
case,  a  small  glass  syringe  and  distilled  water  must  be  used,  to  avoid  the 
premature  decomposition  of  the  medicine." 

In  the  hemorrhage  occurring  in  purpura,  or  after  exhausting  consti- 
tutional diseases,  tonics  should  be  given  in  addition  to  astringents.  In 
chronic  inflammatory  disease  of  the  intestinal  mucous  membrane,  at- 
tended by  a  vitiated  secretion  of  the  follicles,  the  hemorrhage  may  be 
best  treated  by  turpentine.  I  have  elsewlicre  related  two  cases  of  recovery 
by  the  use  of  this  agent,  in  one  of  which  (typhoid  fever)  lumbrici  were 
expelled.  Ergot,  from  the  contracting  influence  which  it  exerts  on  the 
arterioles,  is  also  useful  in  many  cases.  It  is  especially  useful  in  purpura 
hsemorrhagica. 

If  the  hemorrhage  be  duo  to  a  local  cause,  as  lumbrici  or  a  rectal  poly- 
pus, the  treatment  obviously  should  consist  in  the  removal  of  this  cause^ 


INTUSSUSCEPTION.  787 


CHAPTER     XIII 

INTUSSUSCEPTION. 


Intussusception,  or  the  passage  of  one  portion  of  intestine  into 
another,  has  long  been  known  as  an  occasional  accident.  Hippocrates, 
though  debarred  from  the  study  of  morbid  anatomy,  appears  to  have  had 
a  pretty  clear  idea  of  this  lesion,  and  he  suggested  a  mode  of  treatment 
which  has  been  employed  till  the  present  time. 


Intusstisception  -witliotit  Symptoms. 

This  is  not  properW  a  disease.  It  consists  in  a  displacement  Anthout 
any  other  anatomical  change.  There  is,  therefore,  no  obstruction,  in- 
flammation, or  even  congestion  present,  and  no  symptoms.  This  form 
of  invagination  might  ordinarily  be  reduced  by  the  normal  peristaltic  and 
vermicuhir  movements  of  the  intestine. 

Invagination  of  a  portion  of  tiie  small  iiltestine  into  the  part  imme- 
diately below  it  is  often  observed  at  the  post-mortem  examination  of 
young  infants,  who  had  presented  no  symptoms  due  to  the  displacement. 
The  invaginated  mass  is  usually  from  half  an  inch  to  two  inches  in 
length,  and,  as  a  rule,  this  accident  is  multiple.  There  may  be  ten  or 
more  distinct  intussusceptions,  at  distances  of  a  few  inches  from  each 
other.  The  simple  displacement  is  believed  to  occur  ordinarily  at  or  a 
short  time  prior  to  the  moment  of  dissolution.  It  has  been  supposed  to 
be  most  frequent  in  those  who  have  died  of  cerebral  or  spasmodic  dis- 
eases, but  its  occurrence  is  not  unusual  in  other  pathological  states.  I 
have  often  found  it  at  the  post-mortem  examination  of  infants  who  have 
had  subacute  or  chronic  entero-colitis.  Heven  states  that  lie  has  seen  it 
at  the  Salpetriere  more  than  three  hundred  times.  Bihard  has  seen  it 
especially  in  infants  who  have  been  subject  to  constipation.  Any  irri- 
tant, mechanical  or  other,  which  disturbs  the  regular  movements  of  the 
intestines,  doubtless  may  produce  it.  It  has  been  caused  in  the  rabbit 
by  irritating  the  anus. 

It  is  not  improbable  that  simple  intussusception  occasionally  occurs 
temporarily  in  children  whoso  health  remains  good,  when  the  regidar 
movements  of  their  intestines  are  disturbed  by  irritating  ingesta  or  other 
causes.  This  form  of  displacement  never  takes  place  in  the  large  intes- 
tine. It  usual  seat  is  the  lower  part  of  the  jejunum,  and  upper  ]>art  of 
the  ileum.  Since  it  possesses  little  interest  as  regards  pathology,  and 
none  whatever  as  regards  symptomatology  and  therapeutics,  it  may  be 
ignored  in  our  description  of  intussusception. 


788  INTUSSUSCEPTION. 


Intussusception  with  Ssrmptoras. 

Intussusception,  or  invagination,  is  one  of  the  most  painful  and  dan- 
gerous of  human  maladies,  but  fortunately  is  not  very  fre(juent.  I  have 
the  records  of  fifty-two  cases  occurring  in  children,  from  which  the  facts 
contained  in  this  article  are  chiefiy  derived.  The  patients  were  under 
the  age  of  twelve  years. 

Previous  Health. — In  thirty-four  of  the  fifty-two  cases,  the  s<^ate 
of  the  health  previously  to  the  invagination  was  recorded.  From  the 
following  table  it  is  seen  that  half,  or  seventeen,  were  previously  well,  the 
remaining  half  sufleriug  from  some  disease  or  derangement : 

Previons  Health. 


Age.  Guud.     Disease  or  Derangement. 

One  year  or  under .         ....     15  8 

Over  one  year         .....       2  9 

17  17 

MM.  Rilliet  and  Barthez,  whose  views  in  reference  to  intussusception 
are  derived  from  the  examination  of  the  records  of  twenty-five  cases, 
state  that  the  previous  health  is  ordinarily  good,  and  the  intussusception 
is,  therefore,  primary.  Their  remark,  according  to  the  above  statistics, 
is  seen  to  be  correct  as  regards  patients  under  the  age  of  one  year,  but 
incorrect  for  those  over  that  age. 

Most  of  the  seventeen  who  had  previous  ill-health  had  diarrhoea, 
dysentery,  or  constipation,  or  diarrhoja  alternating  with  constipation. 
Of  those  otherwise  affected,  one  had  thread-worms,  two  obscure  ab- 
dominal pains,  one  nausea  and  vomiting,  and  one,  whose  age  Avas  four 
months,  had  had  symptoms  of  invagination  when  ten  weeks  old,  which 
soon  passed  off".  It  is  seen  that  the  preexisting  aff'ections  were  ordi- 
narilv  sucli  as  would  be  likely  to  accelerate  the  movements  of  the  intes- 
tines and  at  the  same  time  render  tliem  irregular. 

Causes. — The  above  statistics,  therefore,  show  that  intussusception  is 
often  preceded  by  disease  or  functional  derangement  of  the  intestines. 
The  two  opposite  conditions,  namely,  constipation  and  the  diarrhoeal 
maladies,  so  often  precede  the  displacement  that  they  must  be  regarded 
as  common  causes.  Another  probable  cause  is  intestinal  worms,  Avhich, 
by  their  mechanical  action,  stimulate  the  intestines.  They  were  present 
in  three  of  the  fifty-two  patients,  though  two  of  the  three  seemed  Avell 
till  the  occurrence  of  the  intussusception,  but  the  other  patient  had 
complained  of  irritation  at  the  anus,  and  ascarides  had  been  found  on 
examination. 

The  use  of  irritating  and  indigestible  food  is  an  occasional  cause. 
Thus,  some  Avho  have  had  intussusception  have  been  in  the  habit  of  taking 
fruits,  candies,  and  pastries  freely.  Such  ingesta  may  be  an  immediate 
cause  by  their  irritating  effect,  or  a  remote  cause  giving  rise  to  diar- 
rhoea, Avhich,  in  turn,  produces  intussusception. 

Sex  is  a  predi.sposing  cause,  since  male  patients  are  largely  in  excess. 
Of  the  twenty-five  cases  collated  by  Rilliet  and  Barthez,  all  but  three 


AGE, 


789 


were  boys.  In  our  own  collection,  the  sex  of  thirty-four  of  the  patients 
was  recorded,  and  of  these  twenty-three  were  boys. 

In  ra.re  instances  external  violence  is  the  apparent  exciting  cause. 
One  patient  received  a  severe  contusion  of  the  abdomen  two  years  before 
death,  and  from  this  time  continued  to  complain  at  intervals  of  pain  in 
the  bowels.  One  writer  also  mentions  the  case  of  a  child  nine  years  old, 
who  received  a  blow  from  a  comrade  at  school,  and  from  this  time  had 
alternately  diarrhoea  and  constipation  till  the  invagination  commenced. 
Killiet  and  Barthez  also  relate  the  cases  of  two  children  who  were  taken 
suddenly  with  invagination  when  their  parents  were  tossing  them  in 
their  arms. 

Age. — Of  the  fifty-two  cases  embraced  in  our  statistics,  the  ages  were 
as  follows  : 


3  were  3  i 

monlhs  old. 

1  was  10  monttis  old. 

2     "     4 

1    "    11 

3      "     5 

1    "    12       '^ 

5     "     6 

2  were  from  1  to    2  years  old 

1   was  7 

8   "         "      2  "     5     " 

1      ^'     8 

8   "         "5  "     12  "       " 

3  were  9 

3  not  given. 

Therefore,  no  cases  occurred  under  the  age  of  three  months,  23  cases 
were  between  the  ages  of  three  and  six  months,  or  nearly  one-half  of  the 
entire  number,  8  between  the  ages  of  six  ^-months  and  one  year,  and 
only  18  between  the  ages  of  one  year  and  twelve.  These  statistics 
correspond,  in  the  main,  with  those  of  Rilliet  and  Barthez,  in  whose 
collection  of  twenty-five  cases  no  one  was  under  the  age  of  four  months. 
Leichtenstern^  says  :  "Half  of  all  invaginations,  according  to  my  statis- 
tics of  four  hundred  and  seventy-three  cases,  occur  during  the  first  ten 
years.  The  first  year  after  the  third  month  is  remarkable  for  a  special 
frequency — one-fourth  of  all  intussusceptions." 

The  great  liability  to  intussusception  in  infancy  is  due  partly  to  the 
anatomical  character  of  the  intestine  in  this  period  of  life,  and  partly, 
doubtless,  to  the  fact  that  there  are  more  frequent  irregularities  in  the 
intestinal  movements  than  in  older  children.  In  the  infant  the  walls 
of  the  intestines  are  thin,  the  mucous  and  muscular  coats  and  the  con- 
nective tissue  being  much  less  developed  than  in  those  that  are  older; 
the  mesentery  and  meso-colon  have  also  greater  depth  as  compared 
with  the  same  in  other  periods  of  life,  except  the  meso-colon  at  the 
points  where  it  passes  over  the  kidneys,  in  which  places  it  is  very  short, 
or  even  in  some  cases  nearly  absent.  Moreover,  the  space  occupied  by 
the  large  intestine,  in  which  [)art  of  the  digestive  tube  intussusception 
commonly  occurs,  is  much  shorter  relatively  to  the  length  of  the  intes- 
tine than  in  those  that  are  older.  In  about  thirty  measurements  which 
I  have  made  of  the  length  of  the  large  intestine  and  the  space  occupied 
by  it,  the  latter  was  found,  on  the  average,  about  one-third  that  of  the 
former,  which,  of  course,  necessitates  doubling  of  the  intestine  on  itsell. 
These  peculiarities  of  structure  in  the  infant  obviously  favor  the  occur- 
rence of  intussusception. 

'  Ziemssen's  Encydop. 


790  INTUSSUSCEPTION. 

Seat  and  Pathological  Anatomy. — While  intussusception  occur- 
rin^r  without  symptoms  is  usually  multiple,  that  form  which  occurs  with 
symptoms  is  oi'diuarily  single.  Two  exceptional  cases  which  I  observed 
will  be  presently  related.  In  one  of  the  cases  embraced  in  the  statistics 
an  invagination  occurred  with  symptoms,  and  coexisting  with  it  was 
another  in  the  small  intestines  apparently  without  symptoms,  and  (i^uickly 
reduced  by  handling. 

While  intussusception  without  symptoms  occurs  in  the  small  intes- 
tine, the  seat  of  intussusception  with  symptoms  is,  with  occasional  ex- 
ceptions, the  colon.  The  colon  constitutes  the  entire  invaginated  mass, 
or  else,  and  more  frequently,  it  forms  the  exterior,  while  the  incarce- 
rated portion  consists  wholly  or  in  part  of  the  ileum. 


Intussusception  in  the  Small  Intestines. 

Bouchut  says:  "  M.  Rilliet  states,  in  a  recent  treatise,  that  in  infancy 
the  intestinal  invagination  is  always  accomplished  at  the  exj)ense  of  the 
large  intestine,  and  that  there  is  never  invagination  of  the  small  intes- 
tine. This  is  incorrect.  I  have  observed  the  small  intestine  invagi- 
nated in  the  adjacent  inferior  part.  Taylor  has  reported  a  case  of  this 
kind  in  a  child  twenty  months  old,  who  died  after  an  attack  of  acute 
peritonitis.  M.  Marage  has  seen  another  case  in  a  child  thirteen 
months  old,  who  recovered  after  having  voided  the  invaginated  portion 
furnished  with  two  of  those  diverticula  so  frequent  in  the  small  intestine 
of  the  fetus." 

But,  from  all  that  appears,  the  case  reported  by  M.  Marage  may  have 
been,  and  probably  was,  an  example  of  the  common  form  of  intussus- 
ception, namely,  of  the  ileum  into  the  colon.  In  Mr.  Taylor's  case  the 
invagination  was  really  of  the  ileum  into  the  colon,  although  a  small 
portion  of  the  ileum  next  to  the  valve  had  not  been  inverted,  so  that  it 
constituted  a  little  of  the  exterior  of  the  mass. 

Nevertheless,  Bouchut  is  correct  in  stating  that  irreducible  and  fatal 
intussusception  may  occur  in  the  small  intestines.  Probably  the  dis- 
placement is  at  first  of  the  simple  variety,  but,  continuing  and  increas- 
ing in  extent,  its  return  becomes  impossible.  The  positive  statement 
of  so  great  an  authority  as  M.  Rilliet,  that  intussusception  Avith  sjniip- 
toms  does  not  occur  in  the  small  intestines,  justifies  the  publication  of 
the  following  cases,  which  establish  the  fact  that  there  are  instances, 
though  not  frequent,  in  which  the  displacement  does  have  this  location: 

Case  I. — Male.  This  patient's  health  had  been  uniformly  good,  and 
nothing  unusual  was  observed  in  his  condition  till  the  age  of  four  and  a 
half  months,  when  he  l)ecame  restless,  as  if  in  almost  constant  pain,  with 
occasional  exacerbations.  Castor  oil  was  prescribed,  which  operated  freely, 
and  then  the  following  mixture  : 

R. — Macjnes.  oalcinat ?)j. 

Tinct.  opii  ciimphorat.  .         .         .         .         .         .         •      5'J- 

Tinct  asafoet ^ss. 

Aq.  anisi 5J.— Misce. 

Dose,  ten  to  twenty  drops,  repeated  according  to  the  pain. 


INTUSSUSCEPTION    IN    SMaLL    INTESTINES. 


79i 


These  remedies  failed  to  give  relief,  as  did  also  chloi'oforiu  given  in 
doses  of  two  drop-;.  After  two  or  three  days,  anoth(jr  set  of  symptoms 
arose,  those  characteristic  .  of  pneumonitis,  to  wit,  hurried  respiration, 
accelerated  pulse,  short  suppressed  cough,  and  expiratory  uKjan.  He  was 
treated  with  the  oiled  silk  jacket,  and  mild  counter-irritation,  and  took 
an  expectorant  mixture  containing  ammonium  carbonate.  In  a  few  days 
the  pulmonary  disease  was  evidently  subsiding,  but  the  pain  in  the  abdo- 
men, with  occasional  exacerl)ations,  continued.  His  countenance  was 
pallid,  and  bore  an  expression  of  suffering.  There  was  no  distention  or 
tenderness  of  abdomen,  and  no  abdominal  tumor.  He  took  little  nutri- 
ment, and  seldom  vomited.  In  the  last  part  of  his  sickness  the  dejections 
were  scanty,  and  the  last  three  days  his  stools  consisted  mainlv  of  mucus 
and  a  little  blood.  The  pain  seemed  to  be  growing  less,  when  he  was 
seized  with  convulsions,  and  died  the  same  day,  precisely  two  weeks  from 
the  commencement  of  his  sickness. 

Sectlo  Cadaver. — Head  not  examined  ;  body  slightly  emaciated ;  rau- 
cous membrane  of  trachea  and  bronchial  tubes  vascular ;  posteri(ir  por- 
tion of  the  lower  lolie  of  each  lung  solid,  of  greater  specific  gravity  than 
water,  and  allowing  only  partial  inflation  ;  it  was  in  the  second  stage  ot 
pneumonitis.  Stomach,  duodenum,  jejunum,  healthy.  In  the  upper  part 
of  the  ileum  was  an  intussusception  two-thirds  of  an  inch  long,  presenting 
no  trace  of  inflammation,  either  within  or  around  it,  and  iis  vascularitv, 
when  it  was  examined  externallv,  did  not  seem  notablv  increased.    Above 


Pig.  33. 


/ 


the  intussu.sception  the  intestine  was  emjity;  below  it,  and  cliiefly  in  the 
small  intestine,  was  a  <lark-c()lored  sul)siance  evidently  i)l«»od,  an<l  giving 
in  a  few  liours  the  offensive  odor  of  decaying  animal  matter.  There  was 
a  pas.sage  through  tiie  intussusception,  at  least  two  or  tliiei-  lini-s  in  diam- 
eter, jus  shown  by  a  |)robe.  TIk;  intussusception  sustained  ilie  weight  of 
si.xteen  inches  of  the  intestine,  and  it  would  apparently  have  sustained  cou- 
sitlerably  more.     The  remaining  organs  were  iiealiliy. 

Case  II. — F.  S.,  a  female  intiuit,  four  months  old,  was  trcate<l  at   the 
New  York  Infiuit  Asvlum  in  June  an<]  July,  l»Go,  for  entero-culiiis,  the 


792  INTUSSUSCEPTION. 

usual  epidemic  of  the  summer  season.  The  foHowing  records  show  the 
state  of  the  bowels  immediately  before  her  death  : 

June  *29th.  Has  five  or  six  stools  daily.  oUth.  Two  stools  in  twenty- 
four  hours.  July  1st.  Had  tW'O  stools  since  the  last  record  ;  no  vomitines 
3d.  Four  stools  in  last  twenty-four  hours.  4th.  The  diarrluea  ccmtiniig. 
as  before  ;  the  stools  about  four  daily.     On  the»6th  of  July  she  died. 

Her  pulse  tluriiig  the  time  in  which  these  records  were  taken  generally 
numbered  about  128  per  minute.  She  was  nmeh  emaciated,  and  the  day 
before  death  she  frequently  struck  her  head  with  her  hand.  The  medi- 
cines employed  were  mainly  aikalies  and  astringents. 

tSedio  Cadaver. — Parietal  bones  united  ;  serous  effusion  over  the  con- 
volutions of  the  bi'ain,  under  the  arachnoid;  occipital  bone  depressed; 
commencing  at  a  point  about  two  feet  below  the  stonuich  were  four  intus- 
susceptions two  or  three  inches  from  each  other.  The  invaginated  masses 
were  from  one  to  one  and  a  half  inches  in  length,  and  three  of  them  were 
found  to  be  very  vascular  in  their  interior.  Above,  between,  and  inune- 
diately  below  the  intussusceptions  the  intestine  was  healthy.  One  of  the 
invaginations  was  tested  by  weight,  and  was  found  to  sustain  a  foot  and 
a  half  of  intestine,  and  would  have  sustained  more.  Water  poured  above 
these  intussusceptions  escajjed  through  them  very  slowly;  no  fibrinous 
exudation  ;  desceuiliug  colon  vascular  and  thickened,  and  soluary  glands 
enlarged. 

The  irreducible  character  of  the  intussusceptions  in  the  above  cases 
was  shown  by  the  fact  that  they  sustained  weights  which  doubtless  pro- 
duced greater  traction  than  that  exerted  by  tlie  intestine  in  its  noi-mal 
action.  That  the  displacement  existed  prior  to  the  moment  of  death 
was  shown  by  tlie  symptoms  in  one  of  the  cases  and  by  the  anatomical 
changes  in  both.  In  oi^e  tlie  capillaries  of  the  incarcerated  mass  were 
ruptured  during  the  last  days  of  life,  so  as  to  produce  sanguineous  stools; 
while  in  the  other  there  was  intense  congestion  of  the  invaginated 
mucous  membrane,  while  that  portion  of  this  membrane  which  was  ad- 
jacent but  not  engaged  was  healthy. 

In  both  patients  the  symptoms  were  less  severe  than  in  ordinary 
cases,  and  they  came  on  more  gradually,  for  the  invaginated  intestine 
was  not  completely  closed,  so  that  it  allowed  the  passage  of  fecal  matter 
in  one  till  the  close  of  life,  and  in  the  other  till  near  its  close.  At  both 
of  the  autopsies  water  poured  into  the  intestines  above  the  invaginations 
passed  slowly  through  them. 

Intussusception  in  the  small  intestines  in  the  infant,  commencing  as 
the  simple  form,  may  become  irreducible,  and  yet  remaining  pervious 
may  continue  for  weeks  without  giving  rise  to  severe  or  dangerous  symp- 
toms.    The  following  case  was  an  example  of  this: 

Case. — Male  child,  died  at  the  age  of  nineteen  months,  the  last  eleven 
of  which  he  was  under  observation.  The  mother  states  that  he  had  never 
been  well  since  the  age  of  one  month,  and  that  there  had  been  little  varia- 
tion in  the  symptoms  of  his  disease.  During  the  period  in  which  he  was 
under  observation,  he  was  ordinarily  fn^tful,  and  frequently  seemed  to  be 
in  considerable  pain.  His  stonuicli  through  this  whole  time  was  so  irri- 
table that  he  rarely  took  more  than  three  or  four  spoonfuls  of  nutriment 
without  vomiting.  There  was  usually  mon;  or  less  diavrlKS'a,  but  no  ten- 
derness or  distention  of  abdomen.     He  became  slowly  but  gradually  more 


INTUSSUSCEPTION    IN    LARGE    INTESTINES.  793 

emaciated,  aud  finally  died  in  a  state  of  extreme  emaciation  and  exliaus- 
tion.     He  had  no  convulsions,  and  was  C(mscious  to  the  last. 

Sectlo  Cadaver. — Brain  not  examined;  lungs  healthy,  except  a  circum- 
scribed portion  which  was  inflamed  at  the  summit  of  the  right  lung;  liver 
small  and  almost  destitute  of  oily  matter,  as  shown  by  the  microscope.  In 
the  jejunum,  about  two  feet  below  the  stomach,  was  an  intussusception 
two  inches  long,  the  intestine  forming  which  seemed  to  have  undergone  no 
structural  change.  Above  tlie  intussusception  the  intestine  was  of  small 
calibre,  and  entirely  empty  and  pale;  below  the  intussusception  the  intes- 
tine was  somewhat  larger  than  above,  but  it  seemed  ipiite  healthv.  The 
invagination  was  sufficiently  pervious  to  allow  water  to  pass  through  it, 
and  it  readily  sustain»l  the  weight  of  two  feet  of  intestine.  From  eight  to 
ten  inches  below  this  intussusception  there  was  another,  which  was  imme- 
diately drawn  out  the  moment  the  intestine  was  disturbed.  The  other 
abdominal  viscera  were  healthy. 

There  is  uncertainty  as  to  the  duration  of  intussusception  in  tlie 
above  case,  but  the  symptoms  indicated  tliat  it  existed  a  considerable 
time  prior  to  death.  There  was  no  strangulation,  nor  indeed  any  ap- 
preciable anatomical  alteration  in  the  coats  of  the  intestine,  but  the  fact 
that  the  invaginated  mass  sustained  two  feet  of  intestine,  and  recpiireJ 
considerable  traction  for  its  reduction,  shows  that  it  Avas  not  a  case  of 
simple  displacement  occurring  at  the  moment  of  death  and  without 
symptoms,  but  was  an  example  of  the  variety  "with  symptoms. 


Intussusception  in  Large  Intestines. 

In  most  cases  of  intussusception  occurring  in  infancy  and  childhood, 
the  ileum  is  invaginated  in  tlie  colon,  or  the  first  })art  of  the  colon  is 
invaginated  in  the  part  succeeding  it.  Intussusception  not  infrequently 
begins  in  the  prolapse  of  the  ileum  through  the  ileo-csecal  valve,  in  the 
same  Avay  that  ])rolai)sc  of  the  rectum  occurs  through  the  sphincter  ani. 
If  death  take  place  early,  only  a  small  portion  of  the  ileum  may  have 
passed  the  valve.  If  the  case  be  protracted,  the  tenesmus  brings  down 
more  and  more  of  the  ileum,  with  its  accompanying  incsentery.  The 
constriction  of  the  valve,  Avhich  acts  as  a  ligature,  soon  prevents  the 
further  descent  of  the  ileum;  and,  the  tenesmus  continuing,  the  next 
step  in  the  displacement  is  the  inversion  of  tlie  caput  coli,  which  is 
drawn  into  the  colon  by  the  descending  mass,  and,  unless  the  case  ter- 
minate by  sloughing  or  death,  the  ascending  and  transverse  portions  of 
the  colon  are  successively  invaginated.  Tlie  records  show  that  intussus- 
ception occurs  as  above  stated  in  a  large  proportion  of  cases.  In  one 
case,  among  those  which  I  have  collated,  the  invagination  j)egaii  a  few 
inches  above  tlie  valve,  so  that  the  ileum  constituted  a  small  portion  of 
the  exterior  of  the  mass.  Occasionally  the  cieciun  is  the  ))art  jtrimarily 
inverted  and  invaginated,  and,  descending  along  the  colon,  it  draws 
after  it  the  ileum,  which  sustains  its  natural  relation  to  the  ileo-ciccal 
valve.  ^VIlen  this  occurs  the  ciucum  is  found  at  the  lower  enil  of  the 
mass,  and  two  orifices  are  obsci'ved,  one  leading  through  the  v.dvi',  and 
the  other  into  the  a))pcndix  vermiforiiiis.      These  two  forms  (»f  invagi- 


79-i  INTUSSUSCEPTION. 

nation — that  in  which  the  ileum,  passed  through  the  iloo-cfecal  valve, 
successively  inverts  and  draws  after  it  the  caput  coli  and  the  divisions 
of  the  colon,  and  that  in  which  the  caput  coli  is  primarily  invaginated, 
and  descending  along  the  large  intestine,  inverts  the  latter,  and  draws 
after  it  the  ileum — constitute  the  vast  majority  of  cases  of  this  disease 
in  the  first  years  of  life. 

I  have  notes  of  45  fatal  cases  occurring  under  the  age  of  twelve 
years,  in  which  the  portion  of  intestine  first  displaced  is  recorded.  In 
4  of  these  the  displacement  was  entirely  in  the  small  intestine,  in- 
volving in  no  way  the  colon  ;  in  38  cases  it  commenced  either  by  pro- 
lapse of  the  ileum  through  the  ileo-crecal  valve,  or  by  the  inversion  of 
the  c?ecum  into  the  ascending  colon,  there  being  perha])S  not  much  dif- 
ference in  the  relative  frequency  of  these  two  modes ;  in  one  case  the 
invagination  was  confined  to  a  segment  of  the  transverse  colon,  in 
another  to  a  segment  of  the  descending  colon,  and  in  the  remaining 
case  to  the  lower  part  of  the  descending  colon  and  the  upper  part  of 
the  rectum.  In  three  instances  the  invaginated  mass  itself  became 
invaginated,  producing  an  intussusception  of  great  thickness,  and  neces- 
sarily fatal. 

Intussusception  is  sometimes  attended  by  so  little  constriction  of  the 
incarcerated  portion  that  it  remains  pervious.  In  such  a  case  life  may 
be  protracted  for  weeks  or  even  months,  without  reduction  of  the  dis- 
placement or  any  material  change  in  it,  the  passage  of  fecal  matter  being 
sufficiently  free  for  the  maintenance  of  life.  Death  finally  occurs  in  a 
state  of  exhaustion.  Thus  in  one  instance  a  child,  four  months  old,  lived 
six  Aveeks  after  the  symptoms  of  invagination  commenced,  and  seventeen 
days  "  with  a  portion  of  the  bowel  protruding  from  the  anus."  It  was 
found  at  the  post-mortem  examination  that  part  of  the  ileum  had  de- 
scended through  the  entire  colon,  and  had  remained  pervious.  In  a  case 
related  by  Dr.  Worthington'  symptoms  of  intussusception  were  present 
for  seven  months  before  death,  and  during  the  last  six  weeks  of  life 
the  invaginated  intestine  protruded  frequently  from  the  anus,  and  was 
replaced  by  the  mother.  In  this  case  "  the  cfecum  was  inverted,  and 
descending  through  the  colon  to  the  lower  portion  of  the  rectum,  car- 
ried with  it  the  ileum  and  the  entire  colon,  except  the  last  ten  or  twelve 
inches."  In  another  case  the  symptoms  indicated  a  continuance  of  the 
disease  for  tliree,  if  not  eight  months.  But  such  cases  are  exceptional. 
Ordinarily  as  the  intestine  becomes  invaginated,  its  mesentery  or  meso- 
colon is  also  invaginated,  and  its  veins  compressed.  The  pathological 
state  of  the  incarcerated  mass  soon  becomes  that  of  intense  conges^on. 
In  infants,  usually  in  a  few  hours,  so  great  is  the  distention  of  the 
capillaries  that  tlicy  give  way,  blood  escapes  into  the  intestine,  and 
passes  from  tlie  bowels  in  scanty  motions.  On  examining  the  invagi- 
nated intestine  after  death,  if  gangrene  have  not  occurred,  it  is  found 
of  a  uniformly  intense  red  color,  sometimes  resembling  to  the  naked 
eye  a  long  and  firm  clot  of  blood.  In  those  who  die  early  no  traces 
of  inflammation  are  seen,  but  in  more  protracted  cases  the  attrition 
between  the  serous  surfaces  excites  local  peritonitis.     In  none  of  the 

'  Amer.  Jour,  of  Med.  i6ci.  iur  January,  1849. 


INTUSSUSCEPTION"    IX    LARGE    INTESTIXE3.  795 

fifty-two  cases  which  I  have  collated  in  which  posi-mortem  examina- 
tions were  made,  did  the  inflammation  extend  more  than  a  few  lines 
beyond  the  invagination.  Usually  the  intestine  forming  the  exterior 
of  the  invaginated  mass  is  much  drawn  together  or  puckered.  In  one 
case  treated  by  myself,  the  entire  large  intestine  which  formed  the  exte- 
rior of  the  mass  Was  compressed  within  a  space  of  six  inches  or  less, 
since  about  twelve  inches  of  the  ileum,  doubled  on  itself,  lay  within  the 
entire  colon  and  protruded  from  the  anus,  the  only  part  of  the  large 
intestine  which  was  inverted  being  the  caput  coli.  In  one  case  six  or 
seven  inches  of  the  ileum,  which  formeil  a  portion  of  the  exterior  of  the 
mass,  Avere  compressed  within  the  space  of  one  inch. 

The  abdomen,  at  first  of  natural  fulness  and  soft,  usually  becomes 
more  and  more  distended  till  the  close  of  life ;  but  in  cases  of  much 
vomiting  the  distention  is  moderate.  This  fulness  is  due  to  gas  and 
fecal  accumulation  above  the  invagination.  The  portion  of  the  intestine 
below  the  displacement  is  ordinarily  empty,  except  that  in  the  infant  it 
commonly  contains  mucus,  mixed  with  more  or  less  blood,  which  has 
escaped  from  the  capillaries  of  the  strangulated  mass. 

Tliere  are  few  anatomical  changes  in  this  disease,  which  do  not  arise 
directly  from  the  intussusception,  and  are,  therefore,  located  either 
within  the  mass  or  in  its  immediate  vicinity.  In  tliose  who  recover  by 
the  process  of  sloughing,  the  cicatricial  contraction  may  give  rise  to 
symptoms  and  lesions  of  greater  or  less  gravity.  Thus  the  late  Sir 
James  Y.  Simpson  examined  a  child  aged  9  years,  who  recovered  with 
loss  of  ten  inches  of  intestine,  and  at  the  meeting  of  the  Medical 
Society^  before  which  the  specimen  was  presented,  remarked  tliat  there 
was  unusual  distention  of  the  cutaneous  veins  of  the  patient,  due  prob- 
ably to  such  compressions  of  the  ascending  vena  cava  by  the  cicatrix, 
that  the  venous  circulation  Avas  obstructed.  Mr.  Charles  King^  relates 
the  case  of  a  child  aged  6  years,  who,  on  the  eleventh  day  of  the  dis- 
ease, voided  the  c:ecuui  ami  a  part  of  the  colon.  Two  days  subsequently 
pulsation  ceased  in  the  left  leg,  and  all  that  part  below  the  ]):itella  be- 
came gangrenous.  The  patient  gradually  recovered  with  loss  of  the 
leg.  The  cause  of  this  unfortunate  sequela  was  doubtless  c.)mpressit.n 
from  the  cicatricial  contraction  of  the  artery  which  supplied  the  leg,  and 
probably  the  formation  of  a  thrombus.  Dr.  F.  Bush^  relates  a  case  in 
which  lie  was  enal)led  to  observe  the  extent  and  appearance  of  the 
cicatrix.  The  jiatient,  aged  twelve  years,  discharge<l  from  the  bowels 
fifteen  to  eighteen  iiu^hes  of  the  ileum  on  the  eighth  day  of  the  intus- 
susception, after  wliich  convalescence  was  rapid.  Fourteen  weeks  later 
the  child  died  from  typhus  fever,  and  at  the  autopsy  "  traces  of  the  dis- 
esised  bowels  were  visible  by  a  contraction  and  puckering  where  tlie 
slough  had  taken  place,  and  the  parts  united."  But  fortunately  in 
most  instances  when  the  intestine  sloughs  and  the  child  survives,  no 
serious  or  permanent  injury  results  from  the  cicatrization.  The  cicatrix 
stretches  little  by  little,  and  acconnuodates  itself  to  the  surrounding  parts. 

>  Trans.  Mcdico-Chir.  Soc,  Edin. 

»   L  .n<lori  LifKM't  for  18.-.4. 

^  Lund.  Mod.  uiid  I'liys.  Journ.  for  Deceiubur  18,  1823. 


796  IXTUSSUSCEPTION". 

Symptoms. — The  symptoms  vary  according  to  the  age  of  the  patient 
and  the  degree  of  strangulation.  Pain  in  the  abdomen,  usually  parox- 
ysmal, is  among  the  first,  and  is  one  of  the  most  conspicuous  sym.ptoms. 
It  is  often  severe,  resembling  the  pain  of  hernia,  and  abating  only  with 
the  failing  strength  of  the  child.  After  the  first  few  days,  if  inflamma- 
tion arise,  the  pain  is  continuous,  though  more  severe  in  p-aroxysms.  At 
first  pressure  upon  the  abdomen  is  tolerated,  but  afterward  there  is 
tenderness.  This  is  due  to  the  inflammation,  which  occurs  in  and 
around  the  invaginated  mass,  and  it  is,  therefore,  confined  to  the  part 
of  the  abdomen  in  which  the  tumor  lies.  At  this  point  also  the  abdo- 
men is  more  full  than  elsewhere,  and  not  infrequently  the  physician  can 
feel  the  invaginated  mass  and  detect  its  exact  location,  and  approxi- 
mately its  extent.  Sometimes,  at  an  early  period  as  well  as  late,  cere- 
bral symptoms  occur,  as  in  a  case  related  by  Dr.  Coggswell,^  which 
terminated  in  convulsions  and  death  on  the  second  day.  Convulsions 
are,  howevei',  comparatively  rare,  and  the  mind  is  generally  clear  till 
the  last  moment.  In  infants  the  countenance,  in  the  interv^als  of  pain, 
in  the  first  stages  of  the  complaint,  is  often  placid  and  not  indicative  of 
any  serious  disease,  but  in  older  patients  constant  and  severe  local 
symptoms,  referable  to  the  intussusception,  commence  early.  At  an  ad- 
vanced period,  whatever  the  age,  the  countenance  becomes  anxious  and 
haggard,  the  eyes  hollow  or  sunken,  the  body  loses  its  plumpness,  and, 
if  the  case  be  protracted,  becomes  emaciated. 

Vomiting  is  rarely  absent ;  in  thirty-nine  out  of  forty-seven  cases  it  is 
stated  to  have  been  present,  in  seven  cases  there  is  no  record  of  this 
symptom,  while  it  is  recorded  absent  in  only  one  case ;  but  in  this  case, 
the  records  of  which  are  very  meagre,  death  occurred  on  the  second  day. 
The  vomiting  becomes  stercoraceous  in  a  few  days,  and  it  ordinarily 
continues  with  greater  or  less  frequency  till  the  period  of  collapse.  It 
relieves  partially  the  distention. 

The  ai)petite  is  impaired  and  often  entirely  lost.  Infimts  at  the  breast 
commonly  nurse,  however,  for  several  days,  probably  from  thirst  rather 
than  hunger. 

In  most  patients  one  natural  evacuation  occurs  from  the  bowels  after 
the  intussusception  commences,  and  then  obstiiuite  constipation  succeeds. 
This  evacuation  consists  of  the  excrementitious  matter  below  the  invagi- 
nation. In  children  under  the  age  of  one  year,  scanty  motions  of  blood 
mixed  with  mucus  begin  to  occur  in  a  few  hours.  In  twenty-seven  chil- 
dren under  this  age  I  find  that  twenty-four  had  such  evacuations,  occur- 
ring in  most  of  them  several  times  in  the  course  of  the  day  ;  in  two  of 
the  twenty-seven  there  is  no  record  of  this  symptom,  but  in  the  remain- 
ing case  it  is  stated  to  have  been  absent.  Scanty  evacuations  of  blood 
unmixed  with  fecal  matter  have  been  considered  pathognomonic  of  in- 
tussusception in  the  infimt,  and  we  see  the  ground  for  such  belief,  but  in 
exceptional  instances  the  invaginated  mass  is  partly  pervious,  and 
although  the  dejections  may  contain  blood,  they  are  also  excrementi- 
tious. In  our  collection  of  cases  are  three  examples  of  this  in  infants 
under  the  age  of  one  year.      One  has  already  Ijeen  referred  to.     In  this 

1  London  Lancet  for  July,  IS'jS. 


DIAGNOSIS.  797 

case  there  w.as  the  rare  anomaly  of  so  lai'ge  an  opening  through  the 
ileo-cfBcal  valve  as  to  allow  not  only  prolapse  and  descent  of  the  ileum 
through  the  entire  colon,  so  as  to  protrude  six  inches  from  the  anus,  but 
also  fecal  passage  through  it  daily. 

In  children  above  tlie  age  of  one  year,  the  capillaries  of  the  invagi- 
nated  intestine  are  not  so  frequently  ruptured  as  under  this  age,  and 
sanguineous  evacuations  are  therefore  less  common.  I  have  records  of 
nineteen  cases  between  the  ages  of  one  year  and  twelve,  in  only  six  of 
which  it  is  stated  that  there  were  bloody  motions,  and  in  these  the  blood 
was  not  passed  frequently,  nor  even  in  some  cases  daily,  as  in  infants, 
nor  in  so  pure  a  state,  unless  in  two  cases,  the  records  of  wliich  arc«not 
explicit  on  this  point.  Two  of  these  six  patients  passed  moderate 
bloody  evacuations  after  protracted  periods  of  constipation,  one  had  fecal 
discharges  with  the  blood  through  the  entire  sickness,  and  in  one  blood 
was  passed  at  first,  but  finally  the  stools  were  entirely  fecal. 

In  those  above  the  age  of  one  year,  obstinate  constipation  was  ordi- 
narily present,  no  dejections,  either  bloody  or  fecal,  occurring  for  several 
davs,  but  there  were  a  few  exceptions.  In  three  cases  the  bowels  were 
relaxed.  The  ileum,  in  these  three,  had  descended  through  the  entire 
colon,  or  the  larger  part  of  the  colon,  and  being  pervious,  the  feces  escaped 
from  the  anus  without  detention  in  the  large  intestine,  or  with  detention 
only  in  its  lower  portion,  and  were  therefore  liquid. 

Tenesmus  is  another  symptom.  It  is  not  always  present,  but  in  a 
large  proportion  of  cases,  even  wben  the  invagination  is  in  tbe  upper 
part  of  the  large  intestine,  it  is  a  frequent  and  distressing  symptom.  It 
often  does  not  commence  till  there  is  a  considerable  amount  of  displace- 
ment, and  it  ceases  when  the  strength  is  much  reduced. 

The  temperature  of  the  surface  is  normal  in  the  commencement  of 
intussusception ;  but  finally,  as  febrile  reaction  comes  on  symptomatic 
of  tbe  inflannnation,  it  rises  and  continues  above  the  healtliy  standard 
till  the  intestine  sloughs,  or  till  the  stage  of  collapse  occurs  which  ushers 
in  death.  The  pulse,  especially  in  the  infant,  is  tranquil  at  first,  but, 
whatever  the  age,  it  soon  becomes  accelerated  from  the  paroxysms  of 
pain,  and  subsequently  from  tiie  inflammation  Avhich  occurs  in  the  in- 
vaginated  mass.  There  is  no  disturbance  of  respiration,  except  tliat  it 
is  somewhat  hurried  from  the  fever,  and  from  the  pain  felt  in  advanced 
cases  on  full  inspiration. 

It  will  be  seen  that  the  symptoms  vary  in  certain  particulars,  under 
the  age  of  one  year,  from  those  occurring  over  that  age,  but  differences 
in  the  symptoms  depend  more  on  the  degree  of  invagination  and  con- 
striction, that  on  tlie  age  and  exact  location  of  the  disease. 

Diagnosis. — The  diagnosis  of  intussusception  is  not,  in  general,  diffi- 
cult, except  at  its  commencement.  When  the  inversion  has  reached 
that  degree  at  which  obstruction  occurs,  the  symptoms  are,  in  most 
cases,  such  that  the  disease  can  be  readily  diagnosticated.  In  tiie  cases 
whose  records  I  have  collated  a  correct  diagnosis  was,  with  few  excep- 
tions, made,  and  at  an  early  jieriod.  In  the  infant,  the  disease  for 
which  intussusception  is  most  frequently  mistaken  is  dysentery,  on  ac- 
count of  the  tenesmus  and  the  muco-sanguincous  stools.     In  c<!rtain  of 


798  IXTUSSUSCEPTIOX. 

the  reported  cases  this  mistake  was  not  roctified  imtil  it  was  ascertained 
that  purgatives  produced  no  fecal  evacuations. 

The  symptoms  which  are  commonly  present,  and  which  indicate  the 
nature  of  the  disease,  are  obstinate  constipation,  vomiting,  paroxysmal 
pain  referred  to  the  seat  of  the  disease,  and  tenesmus.  In  the  infant, 
also,  scanty  evacuations  from  the  bowels  of  mucus  and  blood,  or  of  pure 
blood,  are,  as  we  have  seen,  an  important  diagnostic  sign.  It  should  be 
borne  in  mind,  however,  that  in  exceptional  cases  the  displaced  bowel 
may  remain  pervious,  and  the  usual  symptoms  wliicli  ])0ssess  diagnostic 
value  therefore  be  absent.  There  may  be  no  vomiting  or  tenesmus,  and 
diarrhoea  may  even  occur  in  place  of  constipation,  as  in  the  cases  related 
above.  As  an  aid  to  diagnosis,  it  should  be  stated  that  whatever  the 
a^eof  the  cliild  affected  with  intussusception,  clysters  are  often  adminis- 
tered with  difficulty,  and  are  quickly  and  forcibly  returned,  on  account 
of  the  resistance  opposed  by  the  invaginated  mass.  We  have  stated 
above  that  the  seat  and  even  extent  of  displacement  can  be  ascertained 
in  a  large  proportion  of  cases  by  digital  examination  of  the  abdominal 
walls.  The  tumor  can  be  felt  hard,  elongated,  and  tender  on  pressure, 
so  that  the  diagnosis  is  clear.  If  the  invagination  have  extended  to  the 
lower  part  of  the  large  intestine,  it  can  usually  be  discovered  by  an  ex- 
amination per  rectum. 

Duration. — In  the  following  table,  the  duration  of  the  intussuscep 
tion  in  forty-nine  cases  is  given,  as  nearly  as  it  can  be  ascertained  from 
the  records: 

2  died  the  l.«t  day.  1  died  the    8th  dav. 

1  "  "  10th  " 
1  "  "  14:h  " 
1  lived  nearly  a  weelv,  the  exact 

lime  not  being  given. 
1  lived  6  weeics. 
3,  time  of  death  not  given. 

1  lived  over  a  week.  7  recovered. 

In  two  of  the  three  cases  in  which  the  duration  is  not  stated,  the 
patient  lived  much  longer  than  the  usual  period.  One  of  these  two,  a 
girl  of  six  years,  having  eaten  raw  carrots,  was  seized  with  pain  in  the 
abdomen,  which  lasted  eight  months,  when  she  died.  During  the  last 
three  montlis  slie  passed  mucus  and  blood.  In  this  case  the  ctiecum  had 
descended  to  the  anus,  drawing  witl)  it  the  ileum,  wliich  remained  ])er- 
vious.  The  svmptoms  indicated  tlie  continuance  of  the  invagination  for 
three  months  if  not  eight.  The  other  patient  was  a  boy,  aged  three 
years  and  four  months,  who  complained  of  pain  in  tlie  abdomen  for 
many  months,  and  occasionally  vomited.  During  the  last  six  weeks  of 
his  life,  all  the  ])hcnomena  of  invagination  were  present.  In  this  case, 
also,  the  inverted  caput  coli  liad  descended  along  the  entire  length  of 
the  colon.,  and  at  the  autopsy  it  lay  in  the  rectum. 

In  West's  Treatise  on  Diseas'iS  of  Children  (fifth  edition,  18G6, 
page  504),  it  is  stated  that  death  in  this  complaint  always  occurs  Avithin 
a  week.  The  above  statistics,  however,  show  tliat  there  are  exceptions 
to  this  statement,  although  a  large  majority  do  die  within  the  first  seven 
days.     In  thirty-three  of  the  cases  embraced  in  my  statistics  death  oc- 


6 

"  2d 

4 

"  3d 

2 

'<  4th 

5 

"  5th 

2 

"  eih 

2 

"  7th 

PROGNOSIS.  799 

curred  within  tlie  first  week,  and  in  no  fatal  case  in  which  strancrulation 
vras  complete  was  life  pi'olonged  beyond  the  eighth  day.  In  these  cases 
of  complete  strangulation  the  average  duration  was  3.7  days,  and  the 
largest  number  of  deaths  occurred  on  the  third  day.  Death  on  the  first 
day  is  rare,  but  it  occuri'ed  in  two  of  the  cases  embraced  in  my  statistics. 
Death  at  so  early  a  period  usually  takes  place  in  convulsions  and  coma. 

Prognosis. — Intussusception  is  in  its  nature  so  grave  an  accident 
that  the  physician  called  to  a  case  should  always  explain  its  gravity  to 
the  friends.  But,  while  death  is  the  common  result,  there  are  three 
different  modes  of  termination  in  which  life  is  preserved.  First,  the 
reduction  of  the  incarcerated  intestine,  with  immediate  relief.  There 
can  be  no  doubt  that  it  is  possible  for  intussusception,  when  recent,  to 
be  reduced  by  tbe  unaided  action  of  the  bowels,  in  the  same  way  as  the 
common,  simple  intussusception  in  the  jejunum  and  ileum,  or  as  hernia 
is  reduced,  through  the  vermicular  action  of  the  intestines,  for  some- 
times, as  in  Dr.  Coggswell's^  case,  the  patients  at  some  previous  time 
have  experienced  the  same  symptoms  as  those  which  accompanied  the 
attack,  an<l  which  subsiding,  they  remained  for  a  time  in  ])erfect  health. 
This  termination  is  probably  rare,  if  the  symptoms  be  sufficiently 
marked  to  necessitate  treatment.  Again,  the  intussusception  may  be 
cured  by  early  and  well-applied  treatment.  The  physician  often  suc- 
ceeds in  reducing  the  displaced  intestine,  even  if  the  intussusception  be 
in  the  upper  part  of  the  colon,  if  he  be  called  sufficiently  early,  and 
employ  tlie  proper  measures. 

A  second  mode  of  favorable  termination  is  alluded  to  by  certain 
foreign  writers.  The  intussusception  continues  for  a  considerable  period 
with  the  characteristic  symptoms,  and  then,  as  Bouchut  expresses  it, 
"  the  vomitings  gradually  cease,  the  intestinal  hemorrhage  disa])])ears, 
the  strengtli  returns,  and  the  health  becomes  restored  without  the  ex- 
pulsion of  fragments  of  the  intestine."  What  changes  the  displaced 
intestine  undergoes  in  these  protracted  cases,  wliich  gradually  recover 
without  sloughing,  have  not  been  clearly  ascertained,  although  they 
have  been  the  subject  of  conjecture.  According  to  Rilliet,  a  large  pro- 
portion of  fiivorable  cases  terminate  in  this  manner.  It  does  not  appear, 
however,  from  the  statistics  Avhich  I  have  collected,  that  this  is  a  com- 
mon mode  of  recovery.  The  clinical  history  of  intussusception  estab- 
lishes the  fact  that  in  a  large  majority  of  protracted  cases  there  is 
either  death  or  the  third  mode  of  favorable  termination,  namely,  by 
sloughing. 

But  we  cannot  reasonably  expect  recovery  in  young  children  through 
sloughing  and  the  expulsion  of  the  intestine;  since  few  have  the  recjui- 
site  strength  for  so  tedious  and  exhaustive  a  process.  The  youngest 
child  that  recovered  in  this  way,  so  far  as  I  have  been  able  to  ascertain, 
was  an  infant  thirteen  months  old,  whose  case  was  reported  by  M. 
Marage.  With  the  exception  f»f  this  case,  the  youngest  was  a  boy,  aged 
five  years.  The  older  the  child,  the  greater,  of  course,  the  power  of 
endurance,  and  tlie  better  the  prospect  of  recovery.  Of  the  fifty-two 
cases  whose  records  I  have  collated,  seven  recovered  by  the  sloughing 

*  London  Lancet,  July,  1853. 


800  INTUSSUSCEPTION. 

and  expulsion  of  the  mass.  These  chikb'cn  were  of  the  ages  of  five,  six, 
six,  nine,  ek'ven,  twelve,  and  twelve  years.  The  separation  of  the 
invaginated  mass  occurred  in  six  of  these  hctween  the  sixth  and  twelfth 
days,  Avith  an  average  of  nine  and  a  half  days.  In  the  remaining  case 
the  time  is  not  given.  If,  then,  the  patient  can  be  carried  tliroiigh  the 
first  week  without  too  much  exhaustion,  wo  ■  may  each  day  look  for 
the  discharge  of  the  slough,  the  reopening  of  the  bowels,  and  ultimate 
recovery. 

But  in  those  cases  in  which  the  intussusception  remains  open,  so  as 
to  allow  the  passage  of  fecal  matter,  recovery  is  improhable  unless  the 
displacement  be  diagnosticated  early  and  properly  treated.  If  the  intus- 
susception continue,  it  becomes  greater  and  greater  from  the  absence  of 
strangulation.  Without  inflammation  and  with  little  or  no  congestion 
of  the  disi)laced  portion,  and  without  the  severe  symptoms  which  occur 
in  ordinary  cases,  the  patient  wastes  away,  having  irregular  evacuations 
and  more  or  less  ahdominal  pain,  and  finally  dies  in  a  state  of  emacia- 
tion and  weakness.  In  the  early  stage  of  this  form  of  displacement  it 
is  not  improbable  that  injections  or  inflation,  employed  with  sufficient 
force,  will  give  relief,  but  if  the  early  period  pass  without  such  treat- 
ment, cure  is  impossible  by  the  ordinary  methods.  It  is  in  such  in- 
stances especially,  to  wit,  those  in  which  the  displacement  occurs  with- 
out strangulation  or  inflammation,  and  in  which  fecal  matter  passes 
throuo-li  the  displaced  mass  more  or  less  freely,  that  laparotomy  is  justi- 
fiable, and  is  likely  to  give  relief,  when  injections  and  inflation  have 
been  employed  in  vain.  Jonathan  Hutchinson's  successful  performance 
of  this  operation  in  a  child  of  two  years,  who  had  this  kind  of  displace- 
ment, is  known  to  most  readers.^ 

The  prognosis  is  most  favorable  when  the  displacement  occurs  in  the 
lower  part  of  the  large  intestine,  for  its  reduction  is  then  comparatively 
easy.  An  interesting  case  of  this  kind  was  observed  and  treated  by  Drs. 
O'Dwyer,  Reid,  and  myself,  in  the  New  York  Foundling  Asylum,  in 
1875.  The  child  v/as  a  female,  aged  two  years,  and  had  had  previous 
good  health.  The  invaginated  mass  protruded  like  a  prolapse,  about 
four  inches  outside  of  the  anus.  It  was  cold,  considerable  hemorrhage 
had  occurred  from  it,  and  the  infant  seemed  in  collapse.  When  the 
mass  was  returned  so  far  as  it  could  be  carried  within  the  pelvis,  by  the 
index  finger,  the  lower  end  of  it  could  still  be  felt  like  an  os  uteri.  It 
protruded  four  or  five  times  within  twenty-four  hours,  but,  by  replace- 
ment so  far  as  possible  with  the  fingers,  and  the  use  of  simple  water 
injections,  with  the  hips  elevated,  it  was  finally  permanently  reduced, 
and,  with  the  use  of  stimulants,  she  soon  fully  recovered. 

Mode  of  Death. — This  is  difl"erent  in  different  cases.  It  some- 
times occurs  from  collapse.  At  a  meeting  of  the  New  York  Patholo- 
gical Society,  held  December  10, 1873, 1  presentctl  a  specimen,  showing 
intussusception  occurring  about  one  foot  above  the  ileo-Cciecal  valve,  in 
an  infant  aged  thirteen  months.  On  the  day  before  its  death,  its 
previous  health  having  been  good,  it  seemed  ill,  and  vomited  once  or 
twice,  but  did  not  appear  to  be  in  pain.     It  had  two  evacuations  from 

*  London  Lancet,  November  22,  1873. 


TREATMENT.  801 

the  bowels,  of  the  usual  appearance,  in  the  latter  part  of  the  day.  On 
the  following  morning  it  was  unexpectedly  in  collapse,  and  died  within 
about  twenty-four  hours  from  the  commencement  of  the  sickness.  At 
the  post-mortem  examination  the  cranium  was  not  opened,  but  all  the 
organs  of  the  trunk  were  found  normal  except  the  intussusception.  The 
mass  involved  in  the  displacement  measured  two  and  a  half  inches  in 
length,  and  was  slightly  crescentic.  The  mucous  membrane  above  and 
below  it  had  the  normal  appearance,  as  did  that  of  the  external  or  in- 
carcerating portion  of  the  mass,  while  that  of  the  incarcerated  part  was 
deeply  injected.  Water  poured  into  the  intestine  above  the  invagina- 
tion was  wholly  arrested  by  it.^  But  in  the  majority  of  instances  death 
occurs  from  asthenia,  which  comes  on  gradually,  but  increases  rapidly 
in  consequence  of  the  pain,  vomiting,  and  imperfect  nutrition.  Children 
dying  in  this  Avay  may  have  convulsive  movements  more  or  less  marked, 
but  the  prevailing  characteristic  as  death  approaches  is  extreme  exhaus- 
tion. In  exceptional  instances  the  life  of  the  sufferer  is  cut  short  by 
convulsions  before  the  stage  of  exhaustion  is  reached.  Thus  a  child 
aged  three  years,  whose  case  was  reported  by  Dr.  Isaac  Thomas,^  and 
another,  aged  two  years,-  whose  case  was  reported  by  Dr.  Coggswell,^ 
died  in  convulsions  on  the  second  day. 

Treatment. — It  is  unfortunate,  in  cases  of  intussusception,  that  the 
time  in  which  treatment  can  be  of  most  service  is  likely  to  pass  by  before 
the  true  condition  of  the  intestine  is  detected.  Invagination  being  com- 
paratively rare,  the  patient  is  generally  on  the  first  day  treated  for  colic 
or  dysentery  or  some  other  commtm  affection  cf  the  bowels ;  and  it  is 
often  not  till  the  second  day,  when  the  intestine  has  become  incarcerated, 
that  the  physician  accurately  diagnosticates  the  disease.  The  purgative 
medicines  often  given  in  the  commeiicement  injure  the  patient.  In  fact, 
both  reason  and  experience  teach  us  the  im])r(ipriety  of  using  ])urgatives 
in  this  complaint.  Cathartic  remedies  act  as  a  vis  a  ter<io,  and  may  cause 
still  further  descent  of  the  inverted  intestine.  Yet  such  powerful  agents 
of  this  class  as  quicksilver  have  been  employed.  It  was  administered 
in  two  doses  of  one  ounce  each  in  one  of  the  cases  embraced  in  my  statis- 
tics, l)ut  none  of  the  mineral  passed  the  bowels.  At  the  ])Ost-mortem 
examination  a  considerable  pait  of  it  was  found  in  small  globules,  coated 
with  a  black  layer  consisting  of  the  sulphuret  or  black  oxi<Ie  of  mercury, 
in  the  intestine  above  the  intussusception.  It  need  not  be  added  that  the 
case  was  speedily  fatal. 

The  jtroper  treatment  of  intussusception  consists  in  attempts  to  reduce 
the  displacement  Ijy  pressure  from  below.  The  pressure  may  be  applied 
either  by  li(prKl  injections  into  the  rectum  or  by  inflation  of  the  lower 
intestine  by  air  or  gas. 

Injections  should  be  made  with  lukewarm  water,  for  cold  or  hot  water 
may  cause  contraction  of  the  muscular  fibres  of  the  intestine,  and  increase 
the  constriction.  The  child  should  be  placed  in  bed,  or  in  the  nurse's 
lap,  with  the  nates  elevated  45°.     With  the  common  India-rubber,  or 

J  New  York  Mrdicnl  Record,  April  1,  1874. 
»  Amcr.  Mod    Hccoidi-r,  1823. 
*  London  Lancet,  July,  1853. 

61 


802  INTUSSUSCEPTION. 

better  the  fountain-syringe,  and  the  aid  of  an  assistant,  the  liquid  should 
be  gentlv  thrown  into  the  rectum  until  the  abdomen  is  somewhat  dis- 
tended.  By  carrying  the  fingers,  firmly  but  gently  applied  upon  the 
abdominal  -walls,  along  the  direction  of  the  colon,  the  liquid  is  made  to 
press  against  the  lower  end  of  the  intussusception.  The  same  gentle- 
ness and  perseverance  are  required  in  kneading  and  pressing  the  abdom- 
inal walls  as  in  the  treatment  of  hernia,  bv  taxis.  If  the  invagination 
be  in  the  descending  colon,  probably  only  a  small  quantity  ot  the  liquid 
can  be  injected,  and  it  may  be  forcibly  returned,  but  by  repeating  the 
injections  a  sufficient  quantity  can  ordinarily  be  introduced  to  obtain 
the  full  effect  of  the  mode  of  treatment.  There  is  also  sometimes  an  in- 
creased irritability  of  the  rectum,  even  when  the  intussusception  is  at 
the  upper  extremity  of  the  large  intestine,  so  that  tenesmus  and  expulsive 
efforts  follow  the  introduction  of  the  instrument.  The  assistant  can  aid 
in  overcoming  this  by  pressing  the  soft  parts  of  the  nates  around  the 
instrument. 

If  the  injection  fail  to  reduce  the  displacement,  it  may  be  repeated 
after  allowing  the  patient  to  rest  for  a  while  In  the  Nctv  York  Medical 
Journal  for  May,  1875,  is  the  history  of  an  interesting  case,  which  was 
treated  by  Drs.  Church  and  Warren  of  this  city,  and  is  reported  by  the 
latter.  The  infiint  was  seven  months  old  and  had  the  usual  symptoms 
such  as  frequent  paroxysmal  pain  in  the  abdomen,  vomiting,  tenesmus, 
scanty  muco-sanguineous  stools.  On  the  third  day  injections  were  tAvice 
employed  Avithout  result,  but  on  the  fourth  day  an  injection  of  ten  or 
twelve  ounces  reduced  the  displacement,  and  the  infant  recovered.  In 
a  second  case  treated  by  Dr  Warren  the  age  was  nine  months,  and  a 
tumor  appeared  a  little  above  the  umbilicus  a  few  hours  after  the  com- 
mencement of  the  symptoms.  The  following  is  Dr.  Warren's  account 
of  this  interesting  case,  which  will  give  a  clear  idea  of  the  proper  mode 
of  treatment : 

"  The  patient  Avas  looking  A'ery  pale  and  prostrated,  the  pulse  Avas 
quick  and  feeble,  and  the  skin  cold.  I  at  once  determined  to  use  fluid 
injections,  and,  Avith  the  little  patient  placed  in  a  semiprone  position  in 
his  mother's  lap,  Avith  an  ordinary  Davidson's  syringe  I  commenced  in- 
jecting tepid  soap  and  Avater,  but  after  perhaps  a  gill  had  been  throAvn 
into  tlie  rectum,  it  Avas  almost  immediately  rejected,  very  highly  colored 
Avith  blood,  and  mixed  Avith  it  a  very  small  quantity  of  mucus  and  fecal 
matter;  the  latter,  by  the  Avay,  not  hardened,  but  of  the  consistency  of 
soft  putty.  In  a  second  attempt  the  fluid  Avas  retained  longer,  but  Avas 
after  a  little  Avhile  discharged,  Avith  more  blood  and  mucus,  but  Avith 
much  less  tenesmus  and  pain. 

"  When,  soon  after,  I  made  my  third  attempt,  the  child's  chest  Avas 
rested  upon  the  side  of  its  mother's  lap,  Avith  the  lower  extremities 
elevated  by  an  assistant,  so  that  the  position  Avas  at  an  angle  of  about 
45°,  anus  upAvard.  This  time  I  injected  the  fluid  very  sloAvly,  in  order 
to  avoid,  if  possible,  the  irritation  caused  generally  by  the  frequent 
emptying  and  refilling  of  the  syringe  (Avhich,  by  the  Avay,  is  a  very 
serious  hindrance  to  the  successful  use  of  this  syringe,  and  Avhich  renders 
it  much  inferior  to  the  fountain  or  hydrostatic).  In  this  manner  I  suc- 
ceeded in  injecting,  as  I  estimated  at  the  time,  perhaps  ten  or  twelve 


TREATMENT.  803 

ounces,  and  during  the  operation  the  child  gx'aduallv  became  more  quiet, 
and  had,  when  I  ceased,  foUen  asleep.  Then,  with  the  direction  that 
occasional  doses  of  tinct.  opii  camph.  should  be  administered  during  the 
night,  to  control,  if  possible,  the  peristaltic  action  of  the  intestines,  1  left 
him. 

"  On  the  following  morning,  to  my  surprise,  I  found  the  child  sleep- 
ing ([uietly  and  naturally,  and  I  was  informed  that  at  about  5  A.  M.  (six 
hours  after  my  visit)  he  had  a  movement  of  the  bowels,  which  was  saved 
for  my  inspection,  and  consisted  simply  of  the  enema,  slightly  colored 
Avith  fecal  matter.  From  that  time  he  seemed  to  be  entirely  free  from 
pain,  and  six  or  seven  hours  later  had  a  natural  passage,  after  which  re- 
covery progressed  rapidly,  and  in  a  few  days  he  was  discharged  well." 

The  following  case  is  interesting  as  showing  success  from  the  use  of 
injections  after  the  lapse  of  two  days,  in  a  severe  case,  Avhieh  had  re- 
sisted treatment  on  the  first  day.  The  good  result  was  apparently  in 
great  part  due  to  the  manipulation  which  was  made  so  as  to  press  the 
water  against  the  course  which  intussusceptions  are  known  to  take. 

On  September  10,  1876,  I  visited,  with  Dr.  Gillette,  a  nursing  infant, 
aged  nine  months,  whose  history  was  as  follows :  It  was  habitually  con- 
stii)ated,  but  it  continued  in  its  usual  health  till  September  8,  on  which 
day  it  was  carried  by  its  nurse  to  one  of  the  city  parks.  After  its  re- 
turn it  began  to  be  fretful ;  it  vomited,  and  seemed  to  be  in  pain.  It 
continued  to  vomit  frequently,  especially  after  nursing,  or  taking  drinks, 
and  in  the  ensuing  night  passed  two  scanty  stools  of  mucus  and  blood 
without  fecal  matter.  In  the  morning  of  September  9th,  Dr.  G.  was 
summoned,  who  found  the  pidse  180,  and  temperature  102°,  and  the 
matter  vomited  greenish  like  bile.  In  the  evening  the  temperature  was 
102|°.  Dr.  G.  diagnosticated  intussusception,  and  employed  injections 
of  water,  but  they  were  returned  without  bringing  fecal  matter,  and 
without  apparent  result.     He  also  administered  opiates  by  the  mouth. 

September  10th,  temperature  102^°;  features  pallid,  beginning  to 
have  a  pinched  or  sunken  appearance,  and  indicative  of  much  suffering; 
no  nutriment  is  apparently  retained  on  account  of  the  frequent  vomit- 
ing, and  the  bowels  are  obstinately  constipated.  As  the  symptoms  in- 
dicated rapid  sinking  and  collapse,  consultation  was  called  at  4  P.  M.  It 
Avas  impossiltle  to  detennine  certainly,  through  the  abdominal  walls,  on 
account  of  tbe  distention,  whether  there  was  any  tumor,  but  it  was  my 
opinion,  and  the  opinion  of  one  of  the  other  physicians,  that  a  tumor, 
hard  and  inelastic,  could  be  felt  nearly  in  the  median  line,  bctweeu  the 
umbilicus  and  the  symphysis  pubis.  At  about  5  P.  M.  the  shoulders  of 
the  little  patient  were  lowered,  and  the  nates  elevated,  so  that  the  trimk 
formed  an  angle  of  perhaps  forty-five  degrees  Avith  the  horizontal,  and  a 
large  cpiantity  of  tepid  water  was  gently  passed  into  the  intestine  through 
Davidson's  syringe,  Avith  the  vaginal  nozzle  attached.  It  Avas  imi»f)ssil»le 
to  estimate  the  (piantity  retained,  since  a  consideraljle  part  of  it  escaped, 
although  the  anus  Avas  firudy  pressed  around  the  instnnnent. 

When  the  abdomen  Avas  <listended  as  fully  as  seemed  justifiable,  the 
nates  being  still  elevated,  anrl  the  Vu\n'u\  retained,  so  far  as  possible,  l)y 
firm  |)ressure  upon  the  anus,  the  abdomen  Avas  firmly  and  deeply  kneaded 
by  the  hand,  the  movements  being  made  chielly  from  the  right  lumbar 


804  INTUSSUSCEPTION. 

toward  the  right  inguinal,  and  from  the  right  inguinal  toward  the  hypo- 
gastric region.  The  kneading  Avas  continued  perhaps  eight  or  ten  min- 
utes, and  the  water,  which  contained  no  perceptible  amount  of  fecal 
matter,  blood,  or  mucus,  was  allowed  to  escape. 

After  this  operation  the  child  became  quiet,  sloj)!,  and  the  vomiting 
ceased.  At  our  next  visit  at  7  p.m.,  although  the  severe  symptoms 
had  in  great  part  abated,  and  the  countenance  had  lost  that  pinched 
and  suffering  aspect  which  was  so  prominent  before,  it  was  deemed  best, 
in  consultation,  to  repeat  the  injection,  and  this  time  through  a  rectal 
tube,  which  was  introduced  further  than  the  nozzle  employed  at  the 
preceding  visit.  The  body  was  placed  in  the  same  position  as  before, 
and  the  abdomen  kneaded  in  the  same  manner.  The  water,  when 
allowed  to  return,  brought  no  fecal  matter,  but  the  last  that  flowed  con- 
tained two  shreds,  the  largest  about  one  inch  in  length  by  two  lines  in 
width,  resembling  matted  and  nucleated  epithelial  cells.  It  was  believed 
that  they  were  composed  of  such  cells,  with  perhaps  some  of  the  mucous 
membrane  to  Avhich  they  were  attached,  and  that  they  were  detached 
from  the  invaginated  portion.  An  opiate  mixture  was  now  prescribed, 
to  be  given  sufficiently  often  to  relieve  any  restlessness,  and  keep  the 
patient  quiet,  and  a  flaxseed  poultice  was  applied  over  the  abdomen. 
On  the  following  day  the  temperature  was  103|°,  pulse  158,  and  the 
abdomen  somewhat  distended;  but  the  vomiting  had  ceased,  and  there 
had  been  two  fecal  evacuations  since  our  last  visit.  The  intussuscep- 
tion had  been  relieved,  the  inflammatory  symptoms  soon  abated,  and 
the  infant's  health  was  fully  restored. 

Injections  in  order  to  be  effectual,  and  give  promise  of  success,  must 
be  aided  by  gravitation.  Unless  the  nates  be  so  elevated  as  to  obtain 
the  benefit  of  this  hydraulic  principle,  I  am  convinced  that  inflation  is 
more  likely  to  reduce  the  displacement,  and  if,  after  sufficient  trial  of 
injections,  relief  be  not  obtained  inflation  should  be  em})loycd.  Infla- 
tion produces  an  equable  and  effective  distention  of  the  external  or  in- 
carceratinof  portion  of  intestine,  and  cases  of  cure  by  inflation  have  been 
reported  after  injections  had  failed.  Treatment  by  inflation,  which  in- 
deed ought  to  occur  to  any  intelligent  physician  appreciating  the  ana- 
tomical condition  of  the  parts,  as  the  correct  mode,  was  ])rominently 
brouf^ht  to  the  notice  of  the  profession  in  modern  times  by  Mr.  Samuel 
Mitchell.' 

"I  take  the  liberi'ty,"  he  writes,  "of  suggesting  to  the  profession, 
through  the  medium  of  your  valuable  periodical,  the  trial  of  inflating 
the  bowels  by  means  of  a  glyster-pipe  attached  to  a  common  pair  of 
bellows;  it  has  fallen  to  my  lot  to  witness  several  of  these  most  distress- 
ino-  cases  in  children;  the  nature  of  the  obstruction  was  foretold  during 
life,  and  unfortunately  verified  by  post-mortem  examination.  The  last 
case  of  the  kind  which  came  under  my  care,  al)Out  two  years  since,  pre- 
sented all  the  usual  symptoms:  intolerable  restlessness,  the  most  obsti- 
nate sickness,  the  singularly  distressed  state  of  countenance,  and  shrun- 
ken features.  The  usual  remedies  were  had  recourse  to,  viz.,  Avarm 
baths,  glysters,  anodyne  frictions  over  the  abdomen,  etc.,  but  without 

1  London  Lancet  for  March  17,  1838. 


TREATMENT.  805 

avail.  As  a  forlorn  hope,  I  made  trial  of  inflation  by  the  above  means, 
Avith  the  most  happy  result.  The  sickness  immediately  ceased;  the 
child  within  an  hour  passed  a  natural  stool,  and  in  the  morning  was 
almost  without  ailment." 

This  mode  of  treatment  is  termed  novel  in  the  Lancet,  but  it  is  really 
as  old  as  the  time  of  Hippocrates,  who  speaks  of  throwing  air  into  the 
bowels,  by  Avhich  flatulence  is  imitated  (flatus  immitatur).^  Haller^  also 
recommended  the  same  treatment:  ''Flatus  etiam  immissus  celerrime 
susceptionem  dispellet."  Dr.  David  (ireig^  relates  five  cases  of  success- 
ful treatment  of  intussusception  by  inflation.  The  first,  an  infant  six 
months  old.  previously  in  good  health,  suddenly  became  very  fretful, 
apparently  having  severe  paroxysmal  pain  in  the  abdomen.  She  had 
vomitinji,  and  finally  tenesmus,  with  bloodv  evacuations.  Warm  water 
enemata  could  not  be  employed  on  account,  the  writer  thinks,  of  the 
spasmodic  action  of  the  intestines,  and  an  abdominal  tumor  could  be 
felt  near  the  umbilicus.  Castor  oil  and  a  purgative  powder,  and  ene- 
mata of  water  having  been  employed  in  vain,  and  the  case  becoming 
really  critical  on  the  second  day,  inflation  was  resorted  to.  The  writer 
says:  "  The  nozzle  of  a  small  pair  of  bellows  was  introduced  into  the 
anus,  and  air  injected  to  a  considerable  extent.  Contrary  to  our  expec- 
tation, the  air  passed  readily  into  the  bowel,  and  seemed  to  give  the 
child  great  relief  After  the  injection  it  lay  very  (juiet,  as  if  asleep, 
and  evidently  quite  free  from  pain.  In  about  twenty  minutes  from  the 
time  the  air  injection  was  administered,  a  slight  rumbling  noise  was 
heard  in  the  child's  abdomen,  followed  by  a  crack  so  loud  and  distinct  as 
to  alarm  the  attendants  in  the  room,  who  thought  something  had  burst 
in  the  child's  bowels.  The  child,  however,  continued  as  if  asleep,  and 
free  from  pain,  and  in  about  half  an  hour  a  large  feculent  stool,  slightly 
mixed  with  blood  and  mucus,  was  passed  without  pain.  During  the 
night  the  child  rested  pretty  well,  had  no  return  of  vomiting,  took  the 
breast  as  usual,  and  in  two  days  was  quite  well. 

Another  child,  nine  months  old,  treated  by  Dr.  Greig,  presenting 
nearly  the  same  symptoms  and  the  abdominal  tumor,  also  obtained  re- 
lief by  inflation,  after  castor  oil  and  enemata  had  failed  to  produce  any 
benefit. 

An  apparatus  for  the  production  and  injection  of  carbonic  acid  gas 
has  been  invented  by  Schultz  and  Warker,  of  this  city,  and  is  manufac- 
tured by  them.  It  consists  essentially  of  two  glass  chambers,  one  over 
the  other.  In  the  lower  one  a  bicarbonate  is  placed,  and  in  the  upper 
an  acid  in  a  li(iuid  state.  By  tlie  gradual  admixture  of  the  two,  car- 
bonic acid  is  set  fiee.  An  elastic  tube  conveys  the  gas  from  the  lower 
chamber.  The  apparatus  has  been  used  by  physicians  of  this  city  for 
the  reduction  of  intussusception  and  other  purposes,  and  is  a  useful  in- 
vention. 

'J'lie  same  firm,  and  sevei-al  otiiers  in  this  city,  prepare  for  the  shops 
large  bottles  of  iiighly  charged  carbonic  acid  water,  from  wiiieh  when 

'  Ilippocrntes's  Works,  franslaiod  from  tlie  Gr<»ek  by  Grimm,  4  bd.,  pugo  11)8. 
'^  IMiysioloiiiii  Corp.ilis  Iliiiiiani,  loin    vii    p   95. 
*  Edinburgh  Medical  .Journal,  Ucluber,  1804. 


806  INTUSSUSCEPTION. 

inverted  a  powerful  current  of  carbonic  acid  gas  can  be  obtained.  Two 
or  three  of  these  bottles,  with  a  portion  of  the  tube  from  Davidson's 
syringe,  which  can  be  readily  attached  to  the  stem  from  which  the  gas 
escapes,  constitute  all  that  is  required  for  an  ordinary  case. 

The  following  cases,  which  I  treated  with  Dr.  Biichler,  of  this  city,  in 
1871,  show  what  may  be  achieved  by  inflation,  and  also  the  unfavorable 
result  which  must  uievitably  occur  in  certain  cases.  A  German  infant, 
five  month.s  old,  nursing,  began  to  be  fretful,  crying  often,  on  March  7, 
and  before  night  passed  a  scanty  motion  of  blood.  The  symptoms  con- 
tinuing, I  was  asked  to  examine  the  infant  on  the  10th,  and  learned  the 
following  facts:  It  had  vomited  daily,  had  had  daily  scanty  but  infre- 
quent stools,  consisting  chiefly  of  blood,  accompanied  at  first  by  tenes- 
mus, but  not  within  the  last  day ;  it  continued  to  nurse,  but  was  be- 
coming thinner  and  weaker,  and  was  evidently  in  pain.  The  symptoms 
indicating  the  nature  of  the  disease,  the  abdomen,  which  was  not  dis- 
tended, was  examined  for  the  tumor,  which  was  found  in  the  right  side 
in  the  site  of  the  ascending  colon,  apparently  about  one  and  a  half  to 
two  inches  in  length;  pulse  124  in  sleep;  no  cough.  An  ineffectual 
attempt  was  made  to  reduce  the  intussusception  by  a  very  rude  and 
imperfectly  constructed  apparatus  (the  bellows),  when  from  the  lateness 
of  the  hour  further  treatment  was  postponed  till  early  the  following 
morning.  11th.  Tumor  still  detected  in  the  right  lumbar  region; 
pulse  120  asleep,  150  awake.  By  means  of  Schultz  and  Warkers 
apparatus,  the  intestines  Avere  inflated  so  as  to  produce  very  decided 
prominence  of  the  abdomen,  and  the  abdomen  gently  kneaded.  After 
some  minutes  the  gas  was  allowed  to  escape,  when  the  tumor  had  disap- 
peared. In  a  few  hours,  a  natural  evacuation  occurred  from  the  bowels, 
and  the  infant  has  remained  well  smce. 

The  second  case  ended  unfavorably,  although  the  symptoms  were 
apparently  no  more  grave  than  in  the  case  just  rehited,  and  had  con- 
tinued a  sliorter  time.  This  infant  was  also  of  German  parentage.  The 
tumor,  firm  and  elongated,  could  be  distinctly  felt  in  the  left  lumbar 
region.  In  this  case  the  inverted  bottles  of  carbonic  acid  water  were 
employed,  and  when,  after  considerable  delay  and  kneading  of  the  abdo- 
men, the  gas  was  allowed  to  escape  from  the  intestine,  the  tumor  had 
disappeared.  A  few  hours  afterward  convulsions  occurred,  ending 
fatally.  At  the  autopsy  the  invaginated  mass,  which  was  too  firmly 
strangulated  to  admit  of  reduction  by  inflation,  was  found  in  the  epigas- 
tric region,  having  been  carried  up  from  its  former  position  ))y  the  infla- 
tion of  the  intestine  below.  It  consisted  of  the  terminal  })art  of  the 
ileum,  which  had  passed  through  the  ileo-ceecal  orifice,  and  had  become 
incarcerated  in  the  ascending  colon,  and,  as  is  not  unusual  in  these  cases, 
the  action  of  the  intestines  had  changed  the  location  of  the  tumor  in  the 
abdijmen  from  the  right  to  the  left  side. 

Whether  ah*  or  carbonic  acid  be  employed,  it  is  necessary  to  produce 
distention  of  the  intestine  to  its  fullest  extent  below  the  seat  of  the 
complaint,  without  endangering  rupture,  and  of  course  the  sooner  it  is 
used  the  better  the  chance  of  success.  In  a  few  days  the  displaced 
intestine  has,  in  a  large  proportion  of  cases,  become  so  firmly  incarce- 
rated, and  has  descended  so  far,  that  attempts  to  replace  it,  either  by 


TREATMENT.  807 

injections  or  inflation,  are  unsuccessful;  still,  even  at  a  later  period,  a 
persevering  attempt  should  be  made  if  it  have  not  previously  been 
tried.  If  injections  and  inflation  fail  to  effect  the  desired  result,  the 
employment  of  quicksilver,  by  the  rectum  Avith  the  thighs  elevated,  has 
been  suggested  to  me  as  worthy  of  trial  by  a  physician  of  large  practice 
in  this  city,  ^vho  has  had  considerable  experience  with  intussusceptions. 
This  may  be  a  useful  suggestion,  especially  if  the  invagination  be  in  the 
descending  colon. 

If  the  modes  of  treatment  "whicli  I  have  recommended  above  fail  to 
give  rehef  when  perseveringly  and  sufficiently  employed  in  a  case  of 
acute  intussusception,  the  patient's  state  is  one  of  extreme  peril,  and  the 
prognosis  is  unfavorable.  Yet  recovery  is  possible  in  one  of  two  ways, 
namely,  by  incision  through  the  abdominal  walls  (laparotomy),  and 
reduction  of  the  displacement  by  the  fingers  within  the  abdominal 
cavity;  and  secondly,  by  sloughing  of  the  invaginatcd  mass,  and  union 
by  adhesive  inflammation  of  the  ends  of  the  intestine  which  have  pre- 
served their  vitality.  Atrophy  of  the  imprisoned  part  so  seldom  occurs 
in  a  case  which  has  resisted  injections  and  inflation,  that  it  need  not  be 
considered,  in  this  connection,  as  a  mode  of  recovery. 

Laparotomy  has  been  successfully  performed  in  a  child  aged  two 
years,  as  I  have  stated  above,  by  Dr.  Jonathan  Hutchinson,  of  London. 
Tiie  case  was  one  of  those  exceptional  ones  in  which  great  displacement 
had  occurred  without  strangulation.  It  had  continued  as  indicated  by 
the  sym])toms  about  one  month,  and  a  portion  of  the  intestine  termi- 
nating in  the  ileo-caecal  valve  had  protruded  several  inches  from  the 
anus.  "  The  patient  was  anaesthetized  by  chloroform,  and  the  abdomen 
was  opened  in  the  middle  line  below  the  umbilicus.  The  intussuscep- 
tion was  then  easily  found,  and  as  easily  reduced.  The  after-treatment 
consisted  only  in  the  administration  of  a  few  mild  o|)iates,  and  the  child 
made  a  rapid  recovery.'"^  In  a  case  of  tiiis  kind,  there  can  be  no  doubt 
of  the  propriety  and  necessity  of  laparotomy  as  a  last  resort,  for  there 
being  no  strangulation,  sloughing  could  not  occur,  and  death  sooner  or 
later,  from  exhaustion,  must  be  the  result.  Cases  of  this  sort  have  usu- 
ally been  left  to  perish,  after  the  ordinary  modes  of  relief  have  failed. 
Thus  as  far  back  as  1784,  M.  Robin  published'  the  case  of  a  child  agi'(l 
3i  years,  who  died  after  the  lapse  of  three  months,  with  a  cjccum  pro- 
truding from  the  anus;  and  in  the  Amer.  Journ.  of  Med.  Sci.  for  1849, 
Dr.  Worthington  published  a  similar  case,  in  which  a  child  agetl  three 
years  and  four  months  live<l  a  longer  time.  In  these  days  of  anaes- 
thetics, and  with  the  brilliant  success  of  Hutchinson,  a  ))hysician  would, 
in  my  opinion,  be  rej)rehensible  if  he  allowed  a  child  aged  two  years  or 
over,  with  this  form  of  displacement,  to  perish  without  strongly  advis- 
ing la[)arotomy. 

But  the  question  arises,  whether  in  those  more  frecpient  cases  of 
intussusception  in  young  children  in  which,  after  the  disjjlai-emcnt  has 
continued  a  few  hours,  there  is  such  firm  constriction  of  the  invaginatcd 
mass  that  the  patient  suffers  much  pain  and  constitutional  disturbance, 

»   Luidnn  Liin.-Pt,  XovPintx-r  22,  1873. 
'   M^rii.  (ii;  lAriid.  dc  Cliiiui'r. 


808  INTUSSUSCEPTION. 

and  probably  passes  bloody  stools,  and  injections  and  inflation  have 
failed  to  reduce  the  displacement,  laparotomy  is  justifiable.  This 
operation,  in  tiie  case  of  infants,  has  heretofore  been  regarded  as  so 
dangerous,  and  so  likely  in  itself  to  prove  fatal,  that  the  profession  have 
generally  considered  it  unjustifiable,  believing  that,  although  deatli  was 
nearly  certain  without  it,  the  performance  of  it  did  not  increase  the 
chances  of  a  favorable  result.  Dr.  J.  B.  Sands,  of  New  York,  has 
recently  shown  that  laparotomy  is  justifiable,  as  a  last  resort,  for  the 
relief  of  this  form  of  intussusception,  even  in  the  youngest  infants; 
and  in  the  following  case,  recorded  in  the  Neiv  York  3Iedieal  Journal, 
June,  1877,  saved  the  patient,  Avho  doubtless  would  otherwise  have 
perished. 

On  March  11,  1877,  an  infant  of  six  months  suddenly  presented  the 
characteristic  symptoms  of  intussusception,  such  as  tenesmus,  abdominal 
pain,  vomiting,  and  bloody  stools.  A  few  hours  later,  when  Dr.  Sands 
was  called,  the  pulse  was  rapid  and  feeble,  with  symptoms  of  collapse. 
An  elongated  tumor  could  be  felt  in  the  abdomen,  extending  from  the 
left  iliac  region  to  the  left  hypochondrium,  inelastic,  tender  on  pressure, 
and  dull  on  percussion.  The  lower  end  of  the  invaginated  mass  could 
be  readily  touched  by  the  finger  introduced  into  the  rectum.  The  usual 
methods  to  effect  reduction  were  at  once  employed  with  partial  success, 
for  the  tumor  disappeared  from  the  site  Avhere  it  had  been  discovered,  and 
was  reduced  to  a  small  and  firm  mass,  on  a  level  with  the  umbilicus,  but 
it  resisted  any  further  attempts  to  effect  its  reduction. 

Dr.  Sands  then,  having  etherized  the  patient,  made  an  incision  in  the 
median  line  of  the  abdomen,  extending  downward  about  two  inches  from 
a  point  a  little  below  the  umbilicus.  Through  this  opening,  proceeding 
cautiously,  and  using  as  little  violence  as  possible,  he  was  able,  after 
some  delay,  to  reduce  the  displacement.  The  invaginated  mass,  which 
was  only  one  and  a  half  inches  in  length,  consisted  of  the  terminal  por- 
tion of  the  ileum  and  caecum,  which  had  entered  the  ascending  colon. 
The  wound  was  closed  by  five  silver  sutures,  which  embraced  the  peri- 
toneum, and  the  patient  made  a  good  recovery.  The  operation  was 
performed  eighteen  hours  after  the  commencement  of  symptoms. 

Dr.  Sands  has  collected  the  statistics  of  twenty  cases  of  laparotomy 
for  intussusception  occurring  at  different  ages,  in  which  the  result  was 
stated  Of  these,  seven  recovered,  or  one  in  three  ;  but  he  judiciously 
remarks,  considering  the  gravity  of  the  operation,  that  it  is  doubtful 
whether  future  statistics  Avill  show  so  favorable  a  result  of  laparotomy 
for  this  displacement  as  to  justify  the  frequent  use  of  the  knife.  For 
facts  and  statistics  relating  to  this  sulyect  the  reader  is  referred  to  an 
able  and  elaborate  paper  by  Dr.  Ashhurst.^ 

It  is  obvious  that  the  earlier  the  displacement  is  recognized,  the 
greater  the  probability  of  the  reduction  by  the  judicious  use  of  injections 
and  inflation,  and  it  is  seen  from  cases  related  above  that  this  treatment 
may  be  successful  as  late  as  the  second  or  third  day,  after  previous  at- 
tempts to  reduce  the  intussusception  by  the  same  mcians  have  failed,  and 
when  there  is  that  degree  of  strangulation  that  bloody  stools  occur.    But, 

1  American  Journal  of  the  Medical  Sciences  for  July,  1874. 


TREATMENT.  809 

as  my  own  experience  has  shown  me,  there  is  also  inevitably  a  large 
proportion  of  cases  in  which  the  use  of  injections  and  inflation,  however 
judiciously  and  perseveringly  made,  totally  fail,  and  it  seems  to  me,  in 
the  light  of  present  experience,  that  Avhen  pi-essure  from  below  by  water, 
air,  or  gas,  which  is  the  only  efficient  mode  of  treatment  short  of  the 
knife,  has  been  tried  sufficiently  long  and  often  without  result,  that  it  is 
the  duty  of  the  physician  to  seek  surgical  advice  in  reference  to  lapa- 
rotomy, as  he  would  in  a  case  of  hernia,  especially  since,  under  Lister's 
antiseptic  method,  the  danger  from  severe  operations  appears  to  be  con- 
siderably diminished.  It  may  be  added  that  laparotomy  performed  on 
the  first  or  second  day  Avill  be  much  more  likely  to  save  life  in  ordinary 
cases  than  if  performed  later,  since  the  strangulated  intestine  is  soon 
badly  damaged,  and  a  local  peritonitis  is  likely  to  be  developed  any  time 
after  tlie  first  forty-eight  hours. 

When  an  intussusception  has  reached  that  stage  in  wliich  active  inter- 
ference is  no  longer  proper,  the  physician  can  only  prescribe  opiates, 
with  sustaining  measures  and  an  emollient  poultice  over  the  abdomen, 
and  must  await  the  result.  The  diet  should  consist  of  beef  juice  and 
other  concentrated  nutriment,  which  leaves  little  residuum.  Vomiting, 
wliich  is  so  common,  is  best  controlled  by  bismuth  and  opiates;  convul- 
sions require  the  bromide  of  potassium,  and  an  enema  of  three  to  five 
grains  of  chloral  hydrate,  dissolved  in  a  little  water. 


SECTION   lY. 

DISEASES  OF  THE  GENITO-URINARY  ORGANS. 


Uric  Acid  Infarctions. 

Infarctions  of  uric  acid  or  the  urates  are  very  common  in  newborn 
infants.  They  are  seen,  if  an  opportunity  of  examining  the  tcidneys 
occurs,  as  yellowish-red  lines  in  the  tubules  of  the  kidney,  or  lying  in 
the  pelvis,  forming  small  yellowish  granules.  As  they  ai'e  washed  away 
by  the  urine,  we  often  find  them  upon  the  diaper.  The  irritation  pro- 
duced by  these  infarctions  sometimes  causes  painful  micturition.  Chil- 
dren a  few  months  old,  often  fret  or  cry  from  pain  during  urination,  in 
consequence  of  the  irritating  action  of  the  uric  acid,  while  in  the  in- 
tervals between  the  passing  of  water  they  may  or  may  not  be  free  from 
suffering.  Perhaps  they  pass  only  a  few  drops  of  urine  with  straining, 
and  in  it  we  find  crystals  of  uric  acid  or  the  urates.  Urine  highly  acid 
from  the  presence  of  this  substance,  causes  a  burning  pain  in  the  uiethra, 
and  sometimes  redness  not  only  of  the  urethra,  but  even  of  the  labia 
over  which  the  urine  flows.  Although  infants,  perhaps,  suffer  most 
from  this  cause,  the  same  condition  not  infrequently  occurs  in  older 
children.  Their  urine  ])reviously  normal,  becomes  unduly  acid  from 
some  error  in  feeding  or  in  the  digestive  process,  and  uric  acid  crystals 
or  concretions  form.  An  exaggerated  secretion  of  mucus  occurs  from  the 
surface  of  the  bladder  or  from  the  urinary  canal,  in  consequence  of  the 
irritation  produced  by  the  acid,  and  sometimes  pus-cells  are  also  seen 
under  the  microscope  mixed  with  tlie  mucus. 

The  state  of  the  urine  described  above  should  be  at  once  rectified,  for 
it  furnishes  the  conditions  in  which  calculi  form  either  in  the  pelvis  of 
the  kidney,  or  in  the  bladder.  Urine  unduly  acid  and  irritating,  prob- 
ably at  first  causes  catarrh  of  the  delicate  membrane  lining  the  tubules 
and  pelvis  of  the  kidneys,  and  if  the  irritation  be  sufficiently  severe,  the 
Catarrh  extends  along  the  ureters  to  the  bladder,  causing  a  degree  of 
cystitis.  Now  a  catarrh  of  the  pelvis  of  the  kidney  or  the  bladder, 
greatly  increases  the  tendency  to  the  formation  of  calculi,  since  the 
crystals  become  imbedded  in  the  mucus  which  serves  to  agglutinate 
them.  Uric  acid  when  so  abundant  in  the  urine  as  to  cause  symptoms, 
should  be  at  once  treated,  and  the  acid  neutralized  by  an  alkali.  The 
liquor  potassse,  employed  as  recommended  in  our  remarks  on  the  treat- 
ment of  enuresis,  is  the  best  alkali  for  this  purpose.  For  an  infant  of 
one  year,  two  drops  sufficiently  diluted  in  mucilage  will  be  suliicient, 
repeated  in  three  or  four  hours. 
(810) 


ENURESIS.  811 


Enuresis. 


Enuresis,  or  incontinence  of  urine,  is  a  common  and  troublesome 
infirmity  in  children.  It  occurs  both  in  boys  and  girls,  but  is  more 
common  in  the  former  than  in  the  latter.  In  many  children  it  dates 
back  to  infancy ;  but  others  have  a  respite  from  it  in  the  years  im- 
mediately succeeding  infancy,  until  the  sixth  or  seventh  year,  when  it 
returns.  It  may  be  diurnal  as  well  as  nocturnal,  interfering  seriously 
with  the  comfort  of  tlie  child,  and  rendering  his  schooling  inconvenient; 
but  the  annoyance  which  it  causes  is  commonly  most  at  night,  and  it  is 
for  nocturnal  enuresis  that  the  physician  is  most  frequently  consulted. 
The  child  may  pass  his  urine  in  bed  every  night,  or  even  more  than 
once  each  night,  or  there  may  be  occasional  nights  of  immunity. 

The  bladder  consists  of  three  concentric  coats.  1.  On  the  outside, 
the  peritoneal,  which  covers  the  posterior,  the  superior  part  of  the 
lateral,  and  the  anterior  aspects  of  the  organ.  2.  The  muscular,  Avliich 
chiefly  concerns  us  at  present,  and  which  consists  of  two  layers — the 
one  external,  the  fibres" of  which  have  a  general  longitudinal  direction; 
the  other  internal,  whose  fibres  are  circular.  The  circular  fibres  become 
more  abundant,  producing  greater  thickness  of  this  layer  at  the  urethral 
orifice,  and  they  extend  a  distance  over  the  urethra.  This  increase  in 
the  number  of  circular  muscular  fibres  at  the  urethral  orifice  constitutes 
the  sphincter  vesicae.  The  fibres  in  the  muscular  coat  of  the  bladder 
are  unstriped,  and  are  not  under  the  control  of  the  will. 

A  second  sphincter,  Avhich  aids  materially  in  the  retention  of  urine, 
is  formed  by  the  compressor  urethn\3.  This  muscle,  arising  by  apo- 
neurotic fibres  from  the  ranms  of  the  pubes,  surrounds  the  whole  mem- 
branous portion  of  the  urethra,  extending  from  the  prostate  to  the 
bulbous  portion.  The  compressor  urethrie  is  a  striped  muscle,  and  its 
action  is  therefore  controlled  by  the  will.  Certain  accessory  muscles 
influence  the  retention  as  Avell  as  the  expulsion  of  urine,  to  wit,  the 
levator  ani,  acceleratores  urinic,  and  the  abdominal  muscles. 

Nerves. — The  nmscular  coat  of  the  bladder  receives  its  nerves  from 
the  hypogastric  plexus,  which  belong  to  the  sympathetic  system,  although 
filaments  enter  the  plexus  from  the  spinal  system.  1'he  innervation  of 
the  bladder  is,  therefore,  twofold — that  derived  from  the  sympathetic 
system  {)redominating  over  that  from  the  spinal  system,  as  shown  by  the 
relative  number  of  filaments  from  the  two  sources.  According  to  Belfield, 
the  spin:d  centre  of  the  motor  nerves  of  the  bladder  is  in  the  vicinity 
of  the  third  lumbar  vertebra;  but  JUidge,  in  his  experimi'uts  on  rat)i)its, 
locates  it  in  this  animal  in  the  vicinity  of  the  fourth  lumbar  vertebra. 
The  spinal  centre  of  tlie  nervous  supply  of  the  bladder,  says  C'oidton, 
"  is  connected  with  the  brain  by  a  strand  of  fil)res,  which  may  be  traced 
from  the  cerebral  peduncle  along  the  aiiteiior  colinuns  of  the  spinal 
cord."  Tlie  neck  of  the  bladder,  including  the  sphincter  vesicas  di-rives 
nervous  fibres  ilirectly  fiom  the  anterior  or  motor  roots  of  the  third, 
fourth,  and  fifth  sacral  nerves;  and  it  is  more  abundantly  siijiplied  with 
nervous  filaments  than  is  the  muscular  coat  of  the  organ.  That  the 
sphincter  vesicie  is  under  the  control  of  tlie  will,  is,  therefore,  apparent 


812        DISEASES    OF    THE    GENITO  -  U  RTX  A  R  Y    ORGANS. 

from  the  anatomical  characters,  since  a  strand  of  fibres  connects  the 
peduncles  with  the  motor  centre  of  the  bladder  in  the  spine,  and  this 
centre  connects  with  the  sphincter  through  the  spinal  nerves.  In 
normal  urination,  the  sphincter  is  relaxed  by  the  volition  of  the  indi- 
vidual, ■while  the  muscular  coat  of  the  organ,  being  under  the  control  of 
the  sympathetic  system,  and  involuntary  in  its  action,  expels  the  urine 
as  soon  as  the  sphincter  is  open. 

The  pudic  nerve  also  sustains  an  important  relation  to  the  function 
of  the  bladder.  Arising  from  the  sacral  plexus,  it  is  distributed  "to  the 
base  of  the  bladder,  the  prostate,  the  integument  of  the  penis,  scrotum, 
and  perineum,  the  urethral  muscles  and  mucous  membrane,  and  the 
sphincter  of  the  anus  ;  in  the  female,  the  uterus,  vagina,  and  vulva,  are 
supplied  by  branches  of  the  same  nerve."  Knowledge  of  the  distribution 
of  the  pudic  nerve  enables  us  to  understand  the  manner  in  which  dis- 
ease or  abnormal  conditions  of  the  genital  organs  and  anus  disturb  the 
functions  of  the  bladder.  Irritation  of  the  inferior  branches  'of  this 
nerve  affects  the  action  of  the  superior  branches,  or  those  which  supply 
the  base  of  the  bladder  and  the  urethral  muscles,  so  as  to  produce  in  cer- 
tain patients  dysuria,  or  incontinence,  or  both. 

Etiology. — In  all  cases  the  urine  should  be  examined,  since  the 
cause  of  the  enuresis  is  often  discovered  in  the  deviations  in  it  from  the 
normal  state  \vhich  are  apparent  on  inspection.  The  chief  causes  may 
be  grouped  as  folloAvs,  but  often  two  or  more  of  them  are  present  in  the 
same  case : 

1.  Too  great  acidity  of  the  urine.  The  urine,  in  its  normal  state,  is 
acid  from  the  presence  of  the  acid  phosphate  of  sodium  (Robin),  but  in 
certain  conditions  the  acidity  becomes  so  great  that  the  urine  is  unduly 
stimulating  to  the  surface  of  the  bladder.  Now,  stimulating  or  irri- 
tatinu  urine  causes  the  bladder  to  contract,  iust  as  an  irritating  sub- 
stance  in  the  intestines  increases  the  peristaltic  and  vermicular  move- 
ments of  this  tube.  Excessive  acidity  of  the  urine  is  commonly  due  to 
the  presence  of  uric  acid,  resulting  from  decomposition  of  the  urates ; 
but  in  certain  conditions  lactic  and  hippuric  acids,  resulting  from  faulty 
digestion,  appear  in  the  urine  (Robin);  urine  unduly  acid  renders  its 
retention  difficult,  except  in  moderate  quantity,  so  that  enuresis  results. 

2.  Increased  quantity  of  urine.  This  sometimes  occurs  from  the  free 
use  of  liquids,  as  of  water  or  of  milk.  Renal  disease,  attended  by  an 
exaggerated  excretion  of  urine,  sometimes  produces  enuresis.  Henoch^ 
says:  "■  I  would  advise  you  never  to  omit  an  exammation  of  the  urine, 
because  cases  of  diabetes  mellitus  and  chronic  nephritis  are  known, 
which  were  first  manifested  by  nocturnal  incontinence." 

3.  A  vesical  calculus.  This  is  an  infrequent  cause,  but  Avhen  present 
It  is  likely  to  produce  both  diurnal  and  nocturnal  enuresis.  If  mictu- 
rition be  frequent  and  painful  by  day  and  by  night,  if  the  urine  contain 
a  large  amount  of  mucus  or  muco-pus,  so  as  to  render  it  turbid,  and  if 
the  dysuria  and  frefjuent  urination  be  not  soon  relieved  by  treatment,  a 
calculus  is  probaljly  present.  In  such  cases  the  bladder  should,  of 
course,  be  sounded  by  the  proper  instrument  to  render  diagnosis 
certain. 

'  Diseases  of  Children,  page  257. 


ETIOLOGY.  813 

4.  The  muscular  coat  of  the  bladder  may  have  an  exaggerated  con- 
tractile power  in  itself,  and  not  imparted  to  it  by  any  extraneous  stimu- 
lating agency.  The  surrounding  conditions  may  be  normal,  -while  the 
bladder  is  hypersensitive,  so  as  to  contract  Avith  undue  energy  by 
ordinary  stimulation.  The  fault  is  in  the  bladder  itself,  whose  feinc- 
tional  activity  is  in  excess  ;  this  appears  to  be  the  most  common  cause  of 
enuresis  in  children.  It  is  the  condition  of  the  bladder  which  Trousseau 
had  in  mind  when  he  wrote  :  "  I  repeat  that  the  nocturnal  incontinence 
of  urine  is  a  neurosis,  and  I  now  add  tliat  it  is  a  neurosis  manifesting 
itself  by  excessive  irritability  of  tiie  bladder ;  in  fact,  the  immediate 
cause  of  incontinence  is  this  excess  of  irritability  in  the  muscular  fil)res  of 
the  bladder."  As  Bretonnoau  pointed  out,  children  with  enuresis  from 
this  cause,  habitually  pass  urine  in  a  full  and  rapid  stream,  and,  there- 
fore, in  less  time  than  other  children,  showing  that  the  contractile  power 
of  the  muscular  coat  is  in  excess.  From  the  fiict  that  belladonna  relieves 
so  many  patients,  we  infer  that  irritability  of  the  muscular  coat  is  a 
common  cause  of  enuresis  in  children,  since  this  agent  acts  by  dimin- 
ishing muscular  contractility. 

5.  AVeakness  of  the  muscular  fibres  which  constitute  the  sphincter  of 
the  bladder.  Diminished  tonicity  of  the  sphincter  muscles  does  not  occur, 
or  it  occurs  very  rarely  in  those  who  have  had  previous  good  health,  and 
are  robust.  Ordinai-ily,  children  affected  by  enuresis  from  this  cause 
are  in  h:il)itual  ill  health.  They  have  had  long  and  prostrating  sickness, 
which  has  diminished  muscular  tonicity,  or  they  have  local  disease  in 
the  sj)ine,  or  in  the  course  of  the  spinal  nerves,  which  has  impaired  the 
innervation  of  the  s[)hincter.  Sometimes  incontinence  of  feces  is  also 
present,  and  examination  of  the  sphincter  ani,  by  introducing  the  finger, 
shows  that  its  contractile  power  is  insufficient.  We  infer  the  presence 
of  atony  of  the  sphincter  vesicfe  from  the  atony  thus  easily  discovered 
of  the  sphincter  ani.  As  an  exauiple  of  enuresis  from  atony  of  the 
sphincter  vesicae,  we  may  mention  the  case  of  a  boy  of  thirteen  years, 
Avho  had  "  a  flat  doughy  tumor"  at  the  lower  end  of  the  dorsal  verte- 
brre,  in  the  middle  of  which  a  deficiency  in  the  bony  arch  which  covers 
the  spinal  cord,  was  detected  by  the  fingers,  showing  that  the  tumor 
was  a  spina  bifida,  containing  a  considerable  amount  of  adi|)ose  and 
granulation  tissue.  The  congenital  deficiency  in  the  spinal  column,  and 
conscvpient  injury  of  the  spinal  cord,  had  produced  incontinence  of  both 
urine  and  feces. 

6.  We  have  already,  in  s])eaking  of  tlie  distribution  of  the  pudic 
nerve,  alluded  to  the  fact  that  enuresis  in  children  is  not  infrequently 
produceil  through  reflex  action  by  disease  or  an  abnormal  condition 
external  to  the  bladder,  in  parts  which  receive  their  nerves  fn»m  the 
same  source  as  the  bladder.  Henoch  says:  "  Occasionally  congenital 
phimosis,  stricture  of  the  urethra,  irritation  of  ascarides,  fissure  of  the 
anus,  onanism,  or  vulvitis  can  be  detected,  upon  the  removal  of  which 
the  enuresis  ceases."  I'rousseaii  relates  the  case  of  a  young  man  of 
seventeen  years,  who  from  childhood  had  been  in  the  habit  of  wetting 
his  bed  two  or  three  times  every  night.  After  unsuccessful  trial  of 
belladonna,  strychnia,  and  inastich,  it  occurred  to  Trousseau  that  tiic 
infirmity  might  be  due  to  congenital   phimosis,  and  accordingly  Pro- 


814        DISEASES    OF    THE    GENITO- UHI  N  A  R  Y    ORGANS. 

fessor  Jobert  circumcised  liim.  With  the  exception  of  three  consecutive 
nights,  he  was  entirely  relieved  of  his  enuresis  during  his  subse(i[uent 
stay  of  nine  months  in  the  hospital.  In  dispensary  practice,  in  Ncav 
York  City,  Ave  find  preputial  adhesions,  with  tlie  accumulation  of 
smegma  between  the  glans  and  foreskin,  and  more  or  less  balanitis,  a 
connuon  cause  of  disturbed  function  of  the  bladder.  The  dysuria  and 
enuresis  cease  when  the  adhesions  are  divided  by  the  probe,  the  smegma 
removed,  and  the  preputial  inflammation  or  irritation  has  abat;Ml. 

7.  A  psychical  cause,  to  which  Bartholow  alludes.  The  patient 
dreams  that  he  is  in  a  convenient  place  for  urination,  the  desire  of 
which  is  impressed  on  his  thoughts,  and  awakens  to  find  that  he  has 
urinated  in  bed.      Since  the  action   of  the  bladder  is  laro'cly  under  the 

O       1.'' 

control  of  the  will,  a  strong  will  or  determination — if  the  patient  be  not 
too  sound  a  sleeper,  does  exercise  a  controlling  action  over  the  bladder, 
even  during  sleep.  We  sometimes  observe  this  effect  of  will  jiowcr  in 
the  fact  that  the  patient  breaks  the  habit  of  enuresis  through  a  sense  of 
shame,  or  by  a  determination  to  avoid  the  disgrace.  Thus  one  writer 
mentions  the  case  of  a  girl,  in  whom  severe  flogging  l)y  her  mother  put 
a  stop  to  the  habit,  and  patients  sleeping  away  from  home,  as  when 
visiting  among  friends,  or  at  a  boarding  school,  sometimes  break  the 
habit  through  an  effort  of  the  will.  The  sense  of  profound  shame  which 
the  infirmity  produces,  thus  enables  certain  patients  to  control  the  action 
of  the  bladder  even  in  sleep.  The  state  of  the  mind  should,  therefore, 
be  considered  as  an  element  both  in  the  causation  and  cure  of  the 
infirmity. 

8.  Malformation  of  the  bladder  or  its  appendages.  These  are  of  ^ 
various  kinds.  Some  of  them  are  of  such  a  nature  that  cure  of  the 
enuresis  is  difficult  or  impossible.  Thus,  Thos.  U.  Madden,  M.D., 
F.R.S.C.E.,  relates  the  case  of  a  young  lady,  who  had  been  treated  by 
different  physicians  in  various  localities  with  belladonna,  iron,  vesication 
of  sacrum,  and  the  other  usual  remedies,  Avithout  the  least  benefit.  The 
dribbling  of  urine  was  constant  day  and  night,  so  that  she  was  debarred 
from  schools,  and  ridiculed  and  avoided  by  her  associates. .  She  was 
placed  under  chloroform,  and  her  bladder  was  found  to  have  the  power  to 
retain  a  considerable  amount  of  urine.  Pursuing  the  examination,  Dr. 
Madden  found  that  the  urine  dribbled  from  a  small  orifice  about  half 
an  inch  above  the  meatus  urinarius,  and  covered  by  rugre  of  the  mucous 
membrane.  A  No.  1  catheter  was  introduced  its  entire  length  through 
the  opening,  so  that,  in  the  opinion  of  Dr.  Madden,  there  Avas  malpo- 
sition and  elongation  of  the  right  ureter,  Avhich,  instead  of  emptying  into 
the  bladder,  discharged  the  secretion  of  the  right  kidney  upon  the  vulva. 
In  malformations  like  the  above,  as  Avell  as  in  ectopia  vesicae,  recto- 
vesical, or  vesico-vaginal  fistula,  the  result  of  abnormal  foetal  develop- 
ment, the  urine  obviously  dribbles  constantly,  and  from  the  moment  of 
birth.  In  perpetual  and  lifedong  dribbling,  a  malformation  or  congen- 
ital defect  is  probably  the  cause. 

Prognosis. — The  prognosis  depends  on  the  cause  or  causes  of  the 
enuresis.  Most  of  the  causes  are  of  such  a  nature  that  they  can  be 
removed,  and  the  majority  of  patients  can  therefore  l)e  cured  by  appro- 
priate remedies.     Enuresis  due  to  irritating  properties  in  the  urine,  to 


TREAT  ME  XT,  815 

irritation  or  inflammation  in  the  genital  organs  or  rectum,  and  that  due 
to  exaggerated  tonicity  of  the  muscuhir  coat  of  the  bladder,  can  be  for  the 
most  part  readily  cured  by  appropriate  measures,  while  that  resulting 
from  structural  disease  of  the  spinal  cord,  or  from  malformations  in  the 
urinary  tract,  is  least  amenable  to  treatment. 

It  is  the  common  belief  that  those  epochs  in  life  which  produce  a 
decided  change  in  the  individual,  as  puberty  or  marriage,  are  likely  to 
eifect  a  cure  in  cases  previously  obstinate.  This  opinion  is  to  a  certain 
extent  founded  on  fact.  The  development  of  the  sexual  organs  at 
puberty  seems  to  render  the  bladder  less  irritable  and  more  retentive  in 
some  patients.  Cases  are  also  related,  as  one  by  Trousseau,  in  which 
incontinence  ceased  with  marriage  and  pregnancy.  But  treatment  in 
the  ordinary  form  of  enuresis  should  not  be  deferred  in  the  hope  that 
time  and  physical  changes  will  effect  a  cure^  for  this  belief  is  likely  to 
be  illusory. 

Treatment  — The  physician  asked  to  prescribe  for  a  case  of  enuresis 
should  carefully  examine  the  patient  in  order  to  ascertain  the  cause. 
Since  the  most  common  cause  is  irritability  of  the  bladder,  whether 
inherent  in  the  bladder"  itself,  or  imparted  to  it  by  the  stimulating  prop- 
erties of  the  urine,  the  urine  should  be  rendered  as  bland  and  unirri- 
tating  as  possible.  It  should  be  made,  so  far  as  possible,  as  bland  and 
unirritating  as  tepid  water.  This  is  best  accomplished  by  rendering  it 
neutral.  Excessive  acidity  of  the  urine,  so  common  a  cause  of  enuresis, 
is  promptly  removed  by  the  liquor  potassje  administered  in  doses  of  a 
few  drops  largely  diluted.  I  have  found  it  a  safe  and  efficient  remedy  in 
the  treatment  of  this  infirmity  Avhen  the  bladder  is  unduly  irritable.  If, 
therefore,  in  the  examination  of  a  case  we  discover  no  cause  of  the 
incontinence,  except  an  exaggerated  contractile  power  of  the  bladder, 
and  the  urine  is  acid,  from  three  to  five  drops  of  the  licpior  ])(>tuss;Te 
should  be  given  three  or  four  times  daily,  in  a  wineglasslid  of  gum- 
water,  until  litmus  paper  shows  that  the  urine  is  neutral,  and  its  neutral 
state  should  be  maintained. 

In  belladonna  we  possess  an  agent  which  diminishes  the  functional 
activity  of  the  bladder  when  the  hitter  is  in  excess.  It  diminislies  the 
contractile  power  of  the  muscular  fibres,  and  its  use  is,  therefore,  indi- 
cated in  the  class  of  cases  which  we  are  now  considering.  In  this 
country  the  tincture  of  belladonna  is  more  commonly  emj)loye<l  than 
the  extract,  which  is  used  in  Europe,  especially  in  Continental  Europe, 
and  if  obtained  from  a  good  laboratory  its  action  is  as  certain  as  that  of 
the  extract,  Avhile  its  dose  can  be  better  regulated.  Five  drops  of  the 
tincture  may  be  given  every  evening,  or,  if  the  enuresis  bo  diurnal  as 
well  as  nocturnal,  every  morning  and  evening,  to  a  chihl  of  five  years, 
and  the  dose  be  increased  by  one  drop  every  second  day  if  improvement 
do  not  occur,  and  physiological  effects  are  not  produced,  until  the  dose 
is  doubled,  or  even  trebled.  If  the  enuresis  be  relieved,  or  if.  without 
its  relief,  ])hysiological  effects  be  observed,  as  dryness  of  tiu^  fauces, 
cutaneous  efflorescence,  or  dilatation  of  the  pupils,  the  dose  sliouhl  not 
be  increased.  When  belladonna  ])r()duces  the  desircMl  effect  it  is  no 
doubt  best  to  continue  its  use  fi)r  some  weeks  in  the  dose  which  is  found 
to  be  effectual,  and  then  to  diminish  the  number  of  drops  gradually. 


816        DISEASES    OF    THE     GENIT  0- U  RIN  AR  Y    ORGANS. 

Trousseau,  who,  as  we  have  seen,  considered  enuresis  in  most  cases 
a  neurosis,  highly  extolled  the  treatment  by  belladonna,  believing  it  the 
most  effectual  of  all  methods  of  cure.  He  prescribed  the  extract  of  bel- 
ladonna, gr.  •^,  or  the  sulphate  of  atropia,  gr.  jj^,  but  he  did  not  state 
the  age  of  his  patients.  The  dose  was  increased,  if  necessary,  and 
whatever  dose  he  found  to  give  relief  was  administered  once  daily  for 
three,  four,  or  five  months,  after  which  it  Avas  gradually  diminished, 
but  it  was  not  discontinued  until  after  the  lapse  of  two  to  ten  months. 
By  this  treatment,  Trousseau  states  that  a  majority  of  his  cases  were 
signally  benefited,  and  not  a  few  entirely  relieved.  The  following  case, 
which  recently  occurred  in  my  practice,  indicates  the  mode  of  treatment 
in  enuresis  Avhen  it  results  from  the  cause  which  we  are  now  consid- 
ering: L.,aged  eleven  years,  male,  had  diurnal  and  nocturnal  enuresis, 
which  seriously  interfered  with  his  comfort,  and  rendered  him  an 
object  of  aversion  and  ridicule  among  his  schoolmates,  lie  had  pre- 
viously taken  belladonna  and  other  remedies  without  improvement. 
His  urine  was  found  highly  acid.  Five  drops  of  liquor  potassre  were 
ordered  to  be  given  three  or  four  times  daily,  and  the  tincture  of  bella- 
donna, to  which  he  Avas  accustomed,  was  administered  in  nine  drop 
doses,  tlu'ee  times  daily,  to  be  increased,  if  need  be,  to  fourteen  or  fif- 
teen drops.  The  liquor  potassfB,  in  the  dose  mentioned,  immediately 
rendered  the  urine  neutral,  and  the  enuresis  from  that  time  ceased. 
The  treatment  recommended  above,  of  rendering  the  urine  as  little  irri- 
tating as  possible  by  neutralizing  it,  aided  by  belladonna,  Avhich  dimin- 
ished the  contractility  of  the  muscular  fibres,  cured  the  infirmity,  which 
had  been  most  troublesome  and  tedious. 

If  the  enuresis  be  due  to  an  abnormally  large  secretion  of  urine,  the 
cause  may  be  such  that  something  can  be  done  to  relieve  the  patient. 
The  liquid  ingesta,  in  the  latter  part  of  the  day,  should  be  restricted. 
If  it  be  found  that  the  increased  flow  is  due  to  diabetes  or  chronic 
nephritis,  the  enuresis,  though  an  unpleasant  symptom,  is  comparatively 
unimportant,  and  the  grave  disease  which  causes  it  requires  chief  atten- 
tion. The  quantity  of  urine  may  be  diminished  in  diabetes  mcllitus  by 
the  use  of  proper  food,  and  in  diabetes  insipidus  by  ergot. 

Enuresis  due  to  a  vesical  calculus  is  associated  Avith  symptoms,  as  we 
have  stated  above,  wdiich  indicate  the  presence  of  the  stone,  such  as  pain- 
ful micturition,  which  may  awaken  the  patient  at  night,  and  thus  pre- 
vent the  accident  of  Avhich  Ave  are  treating.  Urination  more  fi-equent 
and  painful  in  the  daytime  than  at  night,  occasional  interruption  in  the 
stream  of  urine  from  the  impediuient,  pus,  perhaps  blood,  and  an  in- 
creased amount  of  mucus  in  the  urine,  indicate  the  presence  of  a  stone. 
Fortunately,  the  calculus  is  easily  detected  by  sounding,  and  by  the 
present  improved  instruments  it  can  be  crushed  and  removed,  or  it  can 
be  removed  by  lithotomy,  Avhich,  in  the  opinion  of  some,  is  less  danger- 
ous, and  is  preferable  to  crushing,  Avhen  the  patient  is  a  child. 

As  we  have  stated  above,  the  physician  should  always  examine  parts 
contiguous  to  the  bladder,  as  the  genital  organs  and  rectum,  in  order  to 
ascertain  if  there  be  any  source  of  irritation  in  them  Avhich  may  pro- 
duce irrital)ility  of  the  bladder  by  reflex  action.  In  some  instances,  as 
we  have  seen,  enuresis  rebellious  to  ordinary  treatment   ceases  Avhen 


TREATMENT.  817 

the  irritation  in  parts  contiguous  to  the  bladder  is  removed.  Phimosis, 
preputial  adliesions,  the  accumulation  of  smegma  between  the  foreskin 
and  glans,  with  more  or  less  balanitis  produced  bv  the  foul  products, 
anal  fissure,  vulvitis,  or  ascarides  should,  if  present,  receive  treatment, 
and  with  the  removal  of  the  irritating  cause  the  enuresis  will  probablv 
cease. 

Cases  in  which  preputial  irritation  produces  an  irritable  state  of  the 
bladder  are  not  infrequent  among  the  poor  of  New  York,  whose  habits 
are  frequently  degraded  and  filthy,  and  the  treatment  consists  in  dividin_<T 
adhesions  of  the  glans  to  the  foreskin,  cleaning  away  the  smegma,  and 
using  a  soothing  ointment.  The  foreskin  can,  with  few  exceptions,  be 
sufficiently  stretched  for  this  purpose,  so  that  incision  or  circumcision, 
which  is  frequently  performed  in  these  cases,  is  unnecessary. 

If  the  enuresis  be  due  to  atony  of  the  sphincter,  a  remedy  is  required 
which  acts  very  differently  from  belladonna.  If  weakness  of  the 
sphincter  be  the  cause,  the  indication  is  obviously  to  increase  its 
tonicity,  and  the  two  medicines  which  have  been  most  successfully 
employed  for  this  purpose  are  nux  vomica,  or  its  active  principle, 
strychnia,  and  ergot.  We  have  stated  that  the  sphincter  is  more  abun- 
dantly supplied  with  nerves  than  is  the  muscular  coat  of  the  bladder, 
so  that  those  agents  which  restore  innervation,  and  thereby  increase 
muscular  tonicity,  act  upon  the  sphincter  more  powerfully  than  upon 
the  muscular  coat.  Ergot  appears  to  exert,  a  similar  action,  though, 
perhaps,  less  in  degree,  upon  the  sphincters  of  the  bladder  and  anus,  to 
that  which  it  exerts  upon  the  uterine  muscular  fibres. 

We  can  obtain  a  clearer  idea  of  the  effect  of  therapeutic  agents  upon 
paresis  of  the  sphincter  vesic.e  by  observing  their  action  in  paresis  of 
the  sphincter  ani,  for  these  two  s])hincters  suffer  loss  of  power  from  the 
same  causes,  and  recover  it  by  the  use  of  the  same  agents. 

In  a  very  instructive  paper  on  incontinence  of  feces,  published  by 
Dr.  George  B.  Fowler,  in  the  Atner.  Journ.  of  Obstetrics,  for  October, 
1882,  two  cases  are  detailed,  showing  unmistakably  the  beneficial  action 
of  ergot  in  increasing  the  tonicity  of  the  sphincter  ani,  and  tiie  same 
treatment  is  indicated  for  urinary  incontinence  when  it  arises  from  a 
similar  cause.  A  child  of  seven  years,  in  tlie  practice  of  Dr.  Fowler, 
had  been  closely  confined  to  his  studies,  with  probably  some  deteriora- 
tion of  his  health,  wlien  fecal  incontinence  commenced.  The  tonicity 
of  the  sphincter  ani  on  examination  with  the  finger  did  not  seem  much 
impaired.  Nevertheless  it  was  so  iiureased  by  ten  drop  doses  of  the 
fluid  extract  of  ergot  that  the  incontinence  was  relieved.  The  second 
patient,  an  an;emic  girl  of  thirteen  years,  had  been  under  treatment 
with  iron  and  other  tonics  without  benefit  to  the  fecal  incontinence. 
Her  flesh  was  flabby  and  surface  cool,  and,  which  is  interesting  to 
remark  as  throwing  light  on  the  condition  of  the  vesical  sphincter, 
when  it  lacks  t(uiicity,  a  lack  of  resistance  in  the  anal  outlet  was  very 
apf)arent  to  the  touch.  A  mixture,  containing  15  minims  of  the  iluid 
extract  of  ergot,  and  grain  y/j^y  of  strychnia,  was  given  three  times 
daily.  At  the  end  of  the  first  week  she  iiad  oidy  two  recurrences  of 
the  trouble,  and  in  tiiree  weeks  was  cured.  Four  months  afterwards, 
although  she  had  been  taking  (piiiiine  and  iron  after  the  discontinuance 

62 


818        DISEASES    OP    THE    GE  NITO- URIN"  AR  Y    ORaANS. 

of  the  ernxot,  a  partial  relapse  occurred,  and  a  suppository  of  five  gra,ins 
of  ergotin,  with  butter  of  cocoa,  was  emplo^'ed  morning  and  evening. 
Immediate  relief  followed,  the  tonicity  of  the  sphincter  was  restored, 
and  the  suppositories  were  discontinued  after  two  weeks.  The  bene- 
ficial effects  of  ergotin  in  weakness  of  the  sphincters  is  shown  by  these 
cases.  Enuresis  from  weakness  of  the  S})hincter  vosicre  could  not  have 
been  better  treated  than  by  the  same  remedies  which  relieved  the  fecal 
incontinence  in  these  two  patients. 

A  considerable  number  of  medicines  have  been  employed  with  more 
or  less  success  for  enuresis,  which  are  now  seldom  used.  According  to 
Bouchut,  M.  Ribes  was  the  first  who  prescribed  nux  vomica.  The 
patient  was  a  soldier,  who  had  both  urinary  and  fecal  incontinence,  and 
was  cured  of  the  weakness  of  the  bladder  in  five  days.  Nux  vomica  is 
employed  instead  of  strychnine,  as  its  use  involves  less  danger.  Mon- 
diere  prescribed  this  agent  in  combination  with  the  black  oxide  of  iron 
in  the  following  formula : 

B  .— Extracti  nucis  vomiriB      .......     sr.  vj. 

Ferri  oxidi  niagnetici       .......      ^j. 

Ft.  pil.  No.  xxiv.     Take  one  pill  three  times  daily. 

Although  we  accept  the  statement  of  Bouchut  that  strychnia  is  an 
"extremely  dangerous"  remedy  for  enuresis,  if  the  patients  be  under 
the  age  of  four  or  five  years,  yet  over  that  age  it  can  be  safely  pre- 
scribed as  an  adjuvant  to  the  ergot  in  proper  dose,  and  with  proper  pre- 
cautions. A  small  dose,  repeated  after  three  hours,  is  obviously  safer 
than  a  larger  dose  at  longer  intervals. 

Among  the  remedies  not  mentioned,  which  have  been  successfully 
employed  in  certain  cases,  the  tincture  of  cantharides  requires  notice. 
In  large  doses,  this  drug  causes  strangury,  but  in  small  doses  causes  such 
irritation  or  stimulation  of  the  surface  of  the  urethra  as  to  increase  the 
contraction  of  the  sphincter,  and  awaken  the  patient  when  the  urine 
presses  upon  the  urethral  orifice,  which  is  rendered  sensitive  by  this 
agent.  Cantharides  is  an  unpleasant  remedy,  and  it  is  not  much  em- 
ployed of  late  years  ;  probably  the  benefit  from  its  use  is  not  usually 
permanent.  A  child  of  five  years  can  take  four  or  five  drops,  largely 
diluted  with  water,  three  times  daily,  and  the  dose  should  be  gradually 
increased  until  there  is  some  evidence  of  its  effect  on  the  outlet  of  the 
bladder. 

Cubebs,  recommended  by  M.  Dieters,  the  various  vegetable  tonics 
and  astringents,  iron,  creasote,  and  many  other  remedies  have  fiillen 
into  disrepute,  and  are  now  seldom  used.  Sometimes  certain  combina- 
tions of  remedies  give  pr()in])t  and  entire  relief.  Eustace  Smith  says, 
"  I  have  lately  cured  a  little  girl,  aged  four  years,  who  had  resisted  all 
other  treatment,  with  the  following  draught,  given  three  times  daily : 

R.— Tinct.  bellad jj. 

Potas.  bromidi  ........     pr.  x. 

Infiis.  digitalis  .         .         .         .         .         .         .         •      3'j- 

Aquae         ........        ad  ^ss. — Misce. 

Ft.  haustus." 

The  tincture  of  belladonna  of  the  British  Pharmacopoeia  has  about 
half  the  strength  of  that  employed  in  the  United  States ;  but,  even  with 


CALCULI,  DY3URIA,  CRYPTORCHIA.  819 

this  allowance,  I  would  not  dare  to  prescribe  so  large  a  dose  of  this 
agent,  except  that  smaller  doses  were  first  used,  and  tolerance  of  the 
remedy  demonstrated. 

Local  treatment  has  been  attended  by  a  degree  of  success.  The  neck 
of  the  bladder  and  the  urethra  have  been  cauterized  by  the  nitrate  of 
silver  applied  by  the  porte-caustique  of  Lalleraand,  with  some  relief  of 
the  enuresis,  at  least  so  long  as  the  soreness  remained.  Baths  and 
douclies  of  cold  water  have  also  been  useii  by  many  physicians,  some 
of  whom,  as  Underwood,  Baudelocque,  Guersant,  and  Dupuytren,  state 
that  they  have  obtained  good  results.  This  treatment  is  most  beneficial 
in  those  cases  in  which  the  sphincter  is  relaxed. 

Finally,  in  certain  patients  the  advice  of  Trousseau  may  be  followed, 
that  the  patient  in  the  daytime  resist  the  inclination  to  pass  urine  so 
long  as  it  does  not  greatly  increase  his  or  her  discomfort;  by  this  means 
greater  tolerance  of  the  presence  of  urine  in  the  bladder  is  produced. 


Calculi,   Dysuria,  Cryptorcliia. 

"We  have  seen,  in  our  remarks  on  uric  acid  infarctions,  how  calculi 
may  form  in  the  pelvis  of  the  kidney,  first  as  small  concretions,  and  how, 
descending  to  the  bladder  they  may  become  nuclei  Avhich  gradually  in- 
crease by  accretions  to  their  surfaces,  or  thgy  may  form  primarily  in 
the  bladder.  A  vesical  calculus  is  not  very  infrequent,  even  in  the 
young  child.  Its  presence  is  manifested  by  dysuria,  and  increase  of 
mucus,  and  the  occurrence  of  pus  and  sometimes  of  blooil  cells  in  the 
urine.  Occasionally  the  flow  of  urine  is  obstructed  by  the  presence  of 
the  calculus,  and  the  consequent  tenesmus  causes  prolapsus  ani.  Pro- 
lapsus ani  and  dysuria  are  important  symptoms  of  stone  in  the  bladder. 
Sometimes  the  bladder  becomes  greatly  distended  with  urine,  and  there 
may  be  trickling  of  it,  with  oedema  and  soreness  of  the  prepuce  and  ad- 
jacent parts.  Now  and  tlien  a  calculus  lodges  in  the  urethra,  ])roducing 
more  or  less  retention  of  urine,  with  oedema  of  the  prepuce  and  adjacent 
parts.  The  treatment  for  calculus  must  be  entirely  surgicah  Lithot- 
rity  as  now  preformed  witii  improved  instruments,  is  devoid  of  danger 
and  successful.  If  a  stone  lodge  in  t!ie  urethra,  it  is  usually  near  its 
outer  extremity  where  the  canal  is  narrowest,  and  it  can  be  removed  by 
a  pair  of  small  forceps. 

Dynuria  occurs  from  various  causes.  It  not  only  results  from  a  cal- 
culus, but  also  from  urine  concentrated  and  acid.  We  have  stated 
above,  that  urine  containing  uric  acid  and  tbe  urates  if  tlicy  are  abun- 
dant is  highly  irritating,  and  while  this  acid  and  its  salts  increa,se  the 
frequency  of  micturition,  they  are  likely  to  render  it  painful.  They 
sometimes  cause  colicky  pain  from  spasmodic  contraction  of  tlie  mus- 
cular fibres  in  the  urinary  tract,  and  even  transient  aUmminuria  lias 
been  noticed.  Dysuria  from  this  cause  is  best  treated  by  alkaline  and 
mucilaginous  drinks. 

Dysuria  not  infrequently  arises  from  a  morbid  state  of  the  external 
genitals,  and  they  should  always  be  examined  when  micturition  is  )>ain- 
ful,  or  obstructed,  to  ascertain  tlieir  condition.     In  the  first  two  or  three 


820        DISEASES    OF    THE    GENITO  -  URIN  AR  Y    ORGANS. 

years  of  life  the  prepuce  is  usually  adherent  to  the  glans  through  epi- 
dermal cel.ls,  which  appear  to  arise  from  the  rete  Malpighii,  and  instead 
of  becoming  Ikm-uv  remain  soft  and  filled  with  pr(>toj)l;ism.  This  ad- 
hesion is  so  common  that  it  must  be  considered  normal,  especially  as  it 
does  not  give  rise  to  symptoms.  But  occasionally,  even  in  young  boys, 
a  pathological  state  sometimes  occurs  which  gives  rise  to  symptoms, 
among  which  is  dysuria.  Phimosis  may  be  present,  retarding  the  How 
of  urine,  some  of  which  is  retained  under  the  foreskin,  where,  decompos- 
ing, it  excites  balanitis,  causes  adhesions,  and  renders  urination  painful. 
Circumcision  ffives  relief  to  the  local  disease  and  the  dvsuria.  In  the 
Outdoor  Department  at  Bellevue  Hos])ital,  where  a  considerable  number 
of  cases  of  this  kind  have  been  brought  for  treatment,  it  has  rarely  been 
necessary  to  circumcise  or  slit  the  prepuce.  Instead  of  this,  the  adhe- 
sions are  divided  by  a  probe,  the  prepuce  stretched  and  drawn  back  so 
as  to  expose  the  glans,  and  the  parts  thoroughly  smeared  with  a  simple 
ointment;  if  there  be  much  inflammation  and  swelling,  it  maybe  neces- 
sary to  etherize  the  patient  for  the  operation. 

In  young  girls  the  labia  minora  are  often  adherent,  apparently 
through  a  catarrhal  inflammation.  They  can,  for  the  most  part,  be 
readily  separated  by  traction,  when  minute  drops  of  blood  appear  upon 
the  exposed  surfaces,  showing  that  a  vascular  connection  has  already 
occurred.  Henoch^  says,  "  In  a  few  cases  this  adhesion  appears  to  me 
to  be  the  cause  of  dysuria,  which  disappeared  after  the  separation  of  the 
labia  from  one  another;  in  others  examination  showed  inflammatory  red- 
ness of  the  introitus  and  meatus,  with  increased  secretion  of  mucus, 
which  renders  the  excretion  of  urine  painful."  Separating  the  adhe- 
rent parts  and  covering  the  surface  with  simple  ointment  to  prevent 
readhesion,  suffice  to  effect  a  cure  of  the  dysuria  when  it  depends  upon 
this  cause. 

In  the  first  months  of  fetal  life  the  testes  lie  in  the  abdominal  cavity 
in  front  of  and  a  little  below  the  kidneys,  behind  the  peritoneum,  and 
attached  to  tfie  base  of  the  scrotum  by  a  long  cord,  the  gubernaculum 
testes.  Between  the  fifth  and  sixth  months  the  testes  descend  to  the 
iliac  fossa,  with  corresponding  shortening  of  the  gubernaculum.  At 
the  end  of  the  eighth  month  it  has  descended  into  the  sci'Otum  sur- 
rounded by  a  jDOuch  of  the  peritoneum,  which  becomes  detached  from  the 
peritoneum  "just  before  birth"  (Gray),  forming  a  closed  sac,  the 
tunica  vaginalis.  It  is  estimated  that  in  one  case  in  five,  the  descent 
of  the  testicle  is  delayed  from  a  few  months  to  a  year  after  birth. 
Astley  Cooper  states  that  the  descent  does  not  occur  in  some  cases  until 
between  the  thirteenth  and  seventeenth  year.  When  there  is  this  late 
descent,  intestine  is  apt  to  follow  the  testicle,  causing  inguinal  hernia. 
In  about  one  case  in  one  thousand,  it  is  estimated,  the  testicle  does  not 
descend,  but  remains  in  the  abdominal  cavity,  either  on  account  of  ad- 
hesions to  the  abdominal  viscera,  the  small  size  of  the  ring,  or  some 
defect  in  the  gubernaculum.  Occasionally,  a  retained  testicle  has  the 
normal  structure  and  development,  but,  as  a  rule,  it  is  imperfect  and 
email,  like  the  testicle  of  the  infant,  and  it  is  prone  to  fatty  or  fibrous 

1  Diseases  of  Children,  Wood  &  Co.,  1882. 


VULVITIS.  821 

degeneration.  If  both  testicles  are  retained,  impotence  may  result  on 
account  of  the  non-development  or  degeneration.  No  treatment  is 
required  for  the  retained  testicle,  unless  it  become  inflamed  when  lying 
in  the  inguinal  canal,  when  it  should  be  treated  by  poultices  and  other 
soothing  remedies. 

Vulvitis. 

Inflammation  of  the  vulva  is  common  in  girls  under  the  age  of  five 
years.  Like  most  other  inflammations,  it  varies  in  severity  in  different 
cases,  from  a  mild  and  transient  attack  to  one  attended  by  tumefaction 
and  excoriation  or  ulceration  of  the  labia,  pain,  and  abundant  discharge. 
Ordinarily  when  the  physician  is  consulted,  the  disease  has  continued  a 
few  days,  and  he  fin<ls  the  vulva  moist  from  a  muco-purulent  discharge, 
whicli  dries  into  light  yellow  crusts,  and  produces  greenish  or  yellowish 
stains  on  the  underclothes.  The  vulva  and  lower  part  of  the  vagina  is 
sensitive  and  red,  and  the  acrid  secretions  sometimes  cause  redness  of 
the  skin  over  which  they  flow.  Frequently  the  labia  are  swollen  and 
tender,  the  patient  may  complain  of  soreness  from  friction  in  walking, 
and  sometimes  dysuria  occurs  from  extension  of  the  inflammation  into 
the  urethra.  In  severe  cases  ulcerations  or  erosions  upon  the  labia  re- 
sult, increasing  the  distress  of  the  patient. 

Vulvitis  is  sometiuies  aphthous.  Small  rounded  elevations  appear 
upon  the  vulva,  and  ulcerate,  and  the  adjacent  surfoce  is  red  and  more 
or  less  swollen.  The  ulcers  are  sensitive  and  painful,  but  under  ordi- 
nary circumstances  they  progressively  heal.  Rarely,  in  those  who  are 
markedly  cachectic,  the  ulcers  become  gangrenous,  and  recovery  is 
te<lious  and  uncertain. 

EriOLOdY. — The  most  common  cause  of  vulvitis  appears  to  be  un- 
cleanliness,  and  hence  its  frequency  in  the  families  of  the  poor  and  de- 
graded in  cities.  Tiie  collection  of  dirt  and  sebaceous  matter  upon 
the  vulva,  and  the  irritation  to  which  it  gives  rise,  which  prompts  the 
j)atient  to  rub  or  scnitch  the  parts,  cause  inflammation.  Perhaps 
among  the  causes  we  may  mention  "taking  cold,"  which  excites  a 
vulvitis,  as  it  sometimes  does  an  otitis  externa.  Struma  strongly  ])re- 
disj)oses  to  this  inllammation,  so  that  slight  irritating  causes  develop  it 
in  those  who  possess  this  diathesis.  A  considerable  proportion  of  those 
who  have  vulvitis,  have  or  have  had  other  manifestations  of  scrofula, 
and  present  the  strumous  aspect,  so  that  it  seems  proper  to  consider 
the  inflammation  of  the  vulva  occurring  under  such  circumstance? 
as  possessing  a  strumous  character,  or  as  a  local  manifestation  of  the 
strumous  diathesis.  We  therefore,  with  Dr.  West,  regard  struma  as  an 
iitipoitant  preilisposing  cause  of  vulvitis  in  the  child.  Ascaridcs  in 
the  rectum  have  long  been  recognized  as  a  cause,  producing  this  effect 
l)V  the  intense  itching  whi<;h  prompts  the  patient  to  rul)  the  parts,  and 
thereby  inflame  them.  It  is  said  that  a.«<carides  sometimes  crawl  to  the 
vulva,  and  prochice  inflammation  by  their  presence  upon  the  sensitive 
surface.  A  last  ami  most  important  cause  is  infection  by  gonorriifPai 
pus.  Every  phvsician  who  sees  cases  in  the  dis|)cnsaries  or  tcticment 
houses  of  our  large  cities,  meets  cases,  even  girls  of  three  or  four  years, 


822        DISEASES    OF    THE    G  ENITO  -  URIN  A  R  Y    ORGANS. 

in  Avhom  the  vulvitis  has  this  cause.  Sometimes  the  gonorrhoea  is  com- 
municated criminally  ;  in  other  instances  it  is  contracted  from  the  in- 
fected seat  of  a  privy,  or  from  soiled  towels  or  linen.  A  young  man 
whom  I  attended,  was  under  treatment  for  gonorrhoea,  when  his  two 
nieces  of  about  four  and  six  years  were  infected  by  the  same  disease, 
probably  from  soiled  towels.  Neither  the  anatomical  characters  nor 
microscopic  appearances  have  thus  far  enabled  us  to  discriminate  between 
gonorrhoeal  and  non-specific  vulvitis,  but  it  is  not  improbable  that  the 
differential  diagnosis  may  yet  be  made  by  observing  the  gonorrhoeal 
microbe  in  the  secretions  of  the  one,  and  its  absence  from  those  of  the 
other.  In  both  forms  of  vulvitis,  the  muco-purulent  secretion  and  the 
inflammatory  lesions  are  identical.  The  danger  of  infecting  the  con- 
junctiva and  producing  purulent  ophthalmia  from  inoculation  WMth  the 
secretion  of  vulvitis,  is  well  known.  On  the  other  hand,  it  is  believed 
by  some  that  vulvitis  is  occasionally  caused  by  inoculating  the  vulva 
with  the  mucopus  of  ophthalmia. 

Treatment. — The  parts  should  be  frequently  bathed  with  tepid 
water  or  mucilaginous  water,  to  insure  complete  cleanliness.  This,  with 
the  use  of  a  mild  astringent  employed  with  a  syringe,  suffices  in  most 
instances  to  produce  immediate  improvement,  and  in  a  few  days  to  effect 
a  cure.  Vaginal  injections  of  tannin  or  alum  (5:  100),  sulphate  of  zinc 
(2  :  100),  or  nitrate  of  silver  (1 :  100),  have  been  employed  with  good 
result  in  this  disease.  I  have  obtained  benefit  from  the  following  mix- 
ture, and  more  frequently  recommend  it  than  any  other  : 

B — Zinci  sulphat.         ......  Qss. 

Plumbi  aoetat 9j* 

Tine,  opii, 

Tine,  catechu  ......  aa   fgi'j- 

Aquae  ad.  f3iv. — Misce. 

To  be  injected  warm  four  or  five  times  daily,  through  a  small  glass  or 
gutta-percha  syringe.  The  same  should  be  applied  with  a  camel-hair 
pencil  to  the  external  parts.     The  following  are  also  useful  formulae  : 

R— Ext.  opii  aq. ^J. 

Liq.  plumbi  subacetat.  dil f5J^'- — Misce. 

B — Pulv.  zinci  oxid.  .....  3J. 

Aeecti  tannic.        .         .         .         .         .         •  .9b 

Mucii.  acacias ^  E^^' 

Aq.  rosae f  5  lijss  — Misce. 

If  ascarides  be  present,  a  cold  rectal  enema  of  lime-water  or  salt  and 
water,  should  be  used  daily.  Benefit  may  be  obtained  from  rectal 
enemas  of  simple  cold  water  even  when  ascarides  are  not  present. 


SECTION  y. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


CHAPTER    I. 

CYANOSIS. 

Certain  of  the  diseases  which  pertain  to  the  circulatory  system  have 
been  treated  of  in  other  parts  of  this  book  (umbilical  hemorrhage,  gastro- 
intestinal hemorrhage,  etc.).  It  remains  to  consider  that  general  condi- 
tion of  the  blood  which  is  designated  morbus  cicruleus,  or  cyanosis. 

In  1863,  I  read  before  the  New  York  Academy  of  ^ledicine  a  statis- 
tical paper  on  cyanosis,  which  was  published  jn  the  Transactions  of  that 
Society.  This  paper  contains  an  analysis  of  lUl  cases,  collated  frum 
the  various  European  and  American  medical  journals,  and  to  those 
cases  I  am  indebted  for  most  of  the  following  facts  pertaining  to  this 
disease. 

The  term  cyanosis  or  blue  disease  is  differently  employed  by  writers. 
Some  apply  it  to  cases  of  transient  iividity  occurring  in  the  course  of 
acute  diseases,  as  well  as  to  those  cases  which  dei)end  on  ])ermanent 
structural  changes,  or  on  malformations.  I  a])])ly  this  term,  as  do  most 
pathologists,  only  to  the  latter  cases. 

The  propriety  of  considering  cyanosis  as  a  distinct  disease  is  apparent 
if  we  are  not  misled  by  the  term  which  designates  it.  Lividity  is  not 
its  most  important  or  its  essential  characteristic.  It  is  simply  a  sign, 
although  consjiicuous,  and,  indeed,  the  only  one  by  wliich  the  disease 
can  be  readily  recognized.  Cyanosis  is,  in  reality,  a  blood  disease,  its 
pathological  state  consisting  in  a  deficient  oxygenation  of  this  fluid,  or 
in  an  excess  in  it  of  carbonic  acid,  and  probably  of  carbonaceous  pro- 
ducts. It  should  be  placed  in  the  same  category  with  leucocytluvmia 
and  melaniemia. 

Statistics  show  that  cyanosis  is,  with  few  exceptions,  due  to  mal- 
formation in  the  circulatory  system,  and  at  the  centre  of  circulation, 
namely,  in  the  heartand  in  the  large  vessels  which  arise  from  this  organ. 
In  exceptional  cases  the  cause  of  cyanosis  is  located  in  the  lungs,  wiien 
it  is  in  all  or  nearly  all  in.stances  either  emphysema  in  both  lungs,  firm 
and  thick  fibrinous  exudation  over  the  lungs,  comj)ressing  them  by 
its  contraction  and  causing,  perhaps,  carnitication  in  |)arts  of  them,  or 
the  cause  is  compression  of  the  lungs  from  caries  of  the  vertebne,  and 
consequent  depression  of  the  ribs.     These  causes  pertain  to  youth  and 

(*823 ) 


82-i  CYANOSIS. 

manhood,  rather  than  to  infancy  and  chiklhood.  On  account  of  this 
fact  and  the  rarity  of  such  cases,  they  need  not  be  considered  in  this 
connection. 

Literature  of  Cyanosis. 

The  ancient  physicians,  so  far  as  can  be  ascertained  from  their  writings 
still  extant,  were  ignorant  of  cyanosis ;  whether  they  overlooked  it,  or 
whether  those  early  ages  were  exempt  from  it  and  the  malformation  on 
which  it  depends  is  peculiar  to  a  posterity  physically  degenerate.  The 
blue  disease  described  by  Hippocrates'  was  probably  some  acute  febrile 
affection.  Galen,  whose  voluminous  writings,  with  an  excellent  index, 
are  still  extant,  and  whose  comprehensive  mind  embraced  the  whole 
range  of  medical  science  of  the  second  century,  makes  no  mention  of  it, 
so  far  as  I  can  find.  In  the  Middle  Ages,  as  appears  from  tlie  remark 
of  Boerhaave,^  the  common  people  believed  the  cyanotic  to  be  the  vic- 
tims of  evil  spirits  ;  and  it  is  probable  that  physicians,  during  this  long 
period  of  superstition  and  intellectual  lethargy,  embraced  the  popular 
belief. 

On  the  revival  of  learning,  pathological  anatomy  began  to  be  more 
thoroughly  and  intelligently  studied ;  but  it  is  evident  that  before  the 
great  discovery  of  Harvey,  in  the  17th  century,  it  was  impossible  to 
refer  cyanosis  to  its  true  cause.  In  the  latter  part  of  the  century  so 
favorably  opened  by  Harvey's  genius,  malformations  of  the  heart  were 
observed  and  described  by  some  pathologists  on  the  continent,  in  cases 
in  which  cyanosis  must  have  been  present:  but  it  is  uncertain,  from  the 
brief  records  which  they  have  left,  whether  any  of  them  understood  the 
dependence  of  this  disease  on  the  abnormal  state  of  the  heart.  Boer- 
haavc,  in  the  beginning  of  the  18th  century,  attributes  "a  livid  or  black 
color  diffused  throughout  the  Avhole  skin,"  evidently  referring  to  cyano- 
sis, to  "  1,  a  relaxation  of  the  vessels,  Avhile  the  vis  a  tergo  remains  the 
same,  or,  2,  to  a  too  sudden  increased  pressure  behind,  without  a  relaxa- 
tion of  the  vessels."  Vieussens,  who  was  a  contemporary  of  Boerhaave, 
and  was  more  thorough  in  the  examination  of  morbid  as  well  as  healthy 
structures,  narrated  the  history  of  a  cyanotic  patient,  with  a  description 
of  the  malformation,  but  the  one  who  first  gave  paiticular  attention  to 
the  blue  disease  was  Morgagni.  This  Paduan  professor,  excelling  his 
predecessors  in  thoroughness  of  observation  and  accuracy  of  deduction, 
published  a  theory  in  explanation  of  the  disease  which  now,  after  the 
lapse  of  more  tlian  a  century,  has  many  adherents.  In  the  same  century 
with  Morgagni,  the  18th,  but  subsefjuently  to  his  time,  Drs.  Pulteney, 
Wm.  Hunter,  Baillie,  Wilson,  and  Abernelhy  in  Great  Britain,  and 
Jurine  and  Sandifort  on  the  continent,  may  be  mentioned  among  those 
who  contributed  to  a  knowledge  of  cyanosis,  by  the  publication  of  cases, 
with  a  description  of  the  malformations.  Yet,  when  the  present  century 
commenced,  nomonograj)h  or  dissertation  had  appeared  on  this  disease  ; 
and,  notwithstanding  the  publication  of  cases  from  time  to  time,  the  pro- 

1  Bft  Morbis,  lib.  ii.  soc  v.  page  4S5,  Ed.  de  Foe'.'S,  1621. 
*  Diseases  of  the  Humurs,  Acad.  Lect.,  ^  732. 


LITERATURE    OF    CYANOSIS.  825 

fession  generally  were  almost  totally  unacquainted  with  its  nature.  No 
better  idea  can  be  given  of  the  prevailing  ignorance,  in  reference  to 
cyanosis  at  this  period,  than  by  quoting  from  a  case  related  by  Kibes  in 
1814.'  The  patient  had  some  time  previously  received  an  injury  of  the 
finger.  '•  Many  physicians  of  Amsterdam,"  says  he,  "were  at  different 
times  consulted  on  the  subject  of  this  aifection,  no  one  of  wiiom  under- 
stood its  true  cause,  its  essential  character.  One  considered  it  as  par- 
taking of  the  nature  of  epilepsy,  and  caused  by  the  irritation  in  the 
nervous  system  which  the  wound  in  the  finger  had  produced.  Others 
attributed  it  to  the  presence  of  intestinal  worms.  Some  physicians  pro- 
nounced it  an  injury  of  the  liver  and  spleen.  Many  held  it  to  be  a 
scrobutic  affection.  One  only  believed  it  to  be  the  result  of  an  unknown 
organic  disease."' 

Since  the  commencement  of  the  present  century  the  blue  disease  has 
received  a  large  share  of  attention.  According  to  Forbes  s  3IedicaI 
Biography,  the  first  dissertation  on  this  sul)ject  appeared  in  1803,  from 
the  pen  of  Seiler,  and  from  this  time  till  1832  no  fewer  than  twenty- 
eight  dissertations  or  monographs  were  published,  either  on  cyanosis  or 
on  malformations  which'  produce  it  or  at  least  relate  to  it.  In  the  list 
of  writers  are  some  of  the  most  eminent  names  in  the  profession,  as 
Louis  and  Bouiliaud.  The  number  who  have  written  on  this  subject 
since  1852  probably  exceeds  the  number  of  previous  writers.  Of  those 
who  have  contriljiited  most  to  our  knowledge  of  the  disease  may  be  men- 
tioned Farre,  Chevers,  and  Peacock  in  Great  Britain,  Gintrac  on  the 
continent,  and  Moreton  Stilie  in  this  country.  Farre,  Chevers,  and 
Peacock  wrote  on  malftrmations  of  the  heart,  alluding  incidentally  to 
cyanosis,  but  their  writings  contain  valuable  niatter  for  statistics  bearing 
on  the  latter  subject.  Farres  book  was  pubHshed  in  1814,  and  is  out 
of  print;  Chevers  published  his  papers  in  the  Loyidon  Med.  Gazette, 
commencing  in  the  year  1845  and  running  through  several  successive 
volumes.  Peacock's  treatise  wsis  published  in  1858.  It  contains 
several  original  ca.ses,  previously  narrated  by  him  to  the  London 
Pathological  Society.  The  paper  by  Moreton  Stillc."  whicli  ha.s  at- 
tracted much  attention,  especially  in  Euroiie,  was  his  inaugural  thesis. 

This  paper  relates  entirely,  in  the  words  of  the  author,  to  '"  the  laws 
of  the  causation  of  cyanosis."  The  only  really  complete  statistical 
paper  on  the  blue  disease  is  that  by  M.  Gintrac,  published  in  1824,  in 
Paris,  and  embracing  all  the  cases  which  had  been  accurately  reported 
up  to  that  time,  namely,  fifty-three.  He,  indeed,  exhausted  the  subject 
for  the  p:.'rioil  in  which  he  wrote,  but  on  account  of  the  accumulation  of 
material  since,  his  monograph  now  seems  inconqilete. 

Two  theories  in  explanation  of  the  occurrence  of  cyanosis  have  divided 
the  profession:  the  one  attributing  it  to  obstruction  at  the  centre  of  cir- 
cufation,  and  conseqiu'ut  venous  congestion  ;  the  other,  to  admixture  of 
venous  ami  artrriid  blood  through  openings  in  the  se|)ta  of  the  luait,  or 
through  tiie  ductus  arteriosus.  The  firmer  of  these  theories  originated 
with  Morgagni  more  than  one  hundre<l  years  ago,  and  is  essentially  the 
same  jvs  that  advocate<l  by  Stilie.    Stillucrrs  in  placing  Morgagni  among 

>   Bull,  do  III  Fhc.  de  Med.,  1815.         »  Ani.r.  .Med.  Jour,  of  Med.  Sei.,  1841 


826  CYANOSIS. 

the  advocates  of  the  other  system.  The  second  theory,  or  that  which 
attributes  cyanosis  to  admixture  of  venous  and  arterial  blood,  is  said  by 
Dr.  Peacock  to  have  originated  with  Hunter,  but  its  ablest  supporter 
was  Gintrac.  Of  late,  there  are  some  ])athologists  who  do  not  believe 
either  theory  is  sufficient  to  explain  the  cause  of  cyanosis,  but  that  the 
true  ex})lanation  lies  somewhere  between  the  two.  Among  the  most 
conspicuous  of  these  is  Prof  Walshe,  of  London.  These  theories  will 
be  considered  in  the  proper  places. 

Sex. — Writers  on  cyanosis  state  that  there  is  a  preponderance  of 
males  to  females  affected  with  it.  Aberle,  of  Vienna,  says  that  two- 
thirds  were  males  in  an  aggregate  of  180  cases  which  he  collated.  In 
Gintrac's  cases,  28  were  males,  and  16  females ;  in  Stille's,  41  were 
males  and  ol  females.  The  sex  is  recorded  in  134  of  the  cases  collected 
by  me,  of  which  78  were  males,  56  females ;  and  if  those  cases  are  ex- 
cluded in  which  cyanosis  was  due  to  obstruction  at  the  mouth  of  the 
pulmonary  artery,  the  number  of  the  two  sexes  is  the  same.  In  the  five 
years  commencing  with  1858,  according  to  the  mortuary  returns,  207 
died  in  this  city  from  cyanosis,  of  which  number  117  were  males,  90 
females.  In  England,  for  two  years,  418  males  died  of  cyanosis,  and 
273  females.  Although  statistics  of  different  cities  and  countries  agree 
in  the  fact  of  an  excess  of  males  over  females,  there  does  not  appear  to 
be  that  great  preponderance  of  males  which  the  earlier  writers  on  this 
disease  believed  to  exist. 

Causes  of  the  Malformations. — Mothers  sometimes  attribute  the 
malformations,  and  probably  coiTectly,  to  strong  mental  impressions  felt 
during  utero-gestation.  The  mother  of  a  ])atient  treated  by  Dr.  Pea- 
cock^ stated  that  "two  months  before  her  confinement,  she  was  fright- 
ened by  seeing  a  child  killed,  and  never  recovered  from  the  shock  she 
sustained.  In  another  case  "  the  mother  was  much  out  of  health,  and 
stated  that,  when  pregnant  with  the  child,  she  was  greatly  alarmed  by 
seeing  a  man  who  Avas  dying  of  asthma."^  In  another  instance  the 
mother  was  frightened  at  the  fifth  month  of  pregnancy  f  and  in  still 
another  case,  recorded  by  Dr.  Peacock,  the  mother,  four  or  five  months 
before  her  confinement,  "  was  greatly  alarmed  by  her  husband,  Avho 
was  insane,  standing  over  her  for  two  hours  with  a  loaded  pistol."* 

Occasionally  the  malformation  appears  to  be  due  to  some  vice  or 
taint  in  the  system  of  one  or  both  parents.  In  a  case  quoted  from 
another  continental  journaP  it  is  stated  that  "the  mother,  who  had 
formerly  suffered  from  rickets,  gave  birth  to  five  children,  all  of  whom 
died  immediately  or  shortly  after  birth  with  symptoms  of  cyanosis. 
The  father  died  at  the  age  of  thirty-six,  of  phthisis."  Dr.  Peacock 
relates  a  case  in  which  the  fitlier  Avas  livid,  and  had  the  "pigeon- 
breast"  common  in  the  cyanotic.  In  the  history  of  a  patient,  which 
was  communicated  by  Cooper  to  Farre,  it  is  related  that  "  vices  of  con- 
formation of  the  heart  appeared  to  have  been  inherent  in  the  family. 
Of  12  infants  only  4  survived,  and  more  presented  signs  of  heart  dis- 

>  Ma'.f.  nf  Heart,  p.  37.  "  Op.  oit  ,  pjii^e  57. 

3  Op.  fit.,  pape  41.  ■•  Oji.  cit.,  jjuge  43. 

6  Guzelle  Medicale,  for  December  28,  1850. 


TIME    OF    COMMEXCEMENT.  827 

ease."  Dr.  Buchanan  relates  the  history  of  a  child  which  was  the 
second  that  had  suffered  and  died  in  the  same  family  in  the  same  way. 
A  patient  treated  by  jNlr.  Leonard  was  the  sixth  child  of  a  fiimily,  who 
had  died  at  about  the  same  age,  with  symptoms  of  cyanosis.  Such 
instances  are,  however,  exceptional.  Ordinarily,  the  cyanotic  have  not 
only  healthy  parents,  but  healthy  brothers  and  sisters. 

A  patient  whose  history  is  given  by  Dr.  AVilliam  Hunter  was  born  at 
the  eighth  month,  but  in  nearly  all  other  cases  the  full  period  of  intra- 
uterine existence  was  reached. 

The  opinion  was  expressed  by  Gintrac  that  the  number  affected  Avith 
cyanosis  to  the  entire  population,  varies  in  different  countries.  It  is 
probable  that  the  occurrence  of  the  blue  disease  is  not  greatly,  if  at  all, 
influenced  by  the  nationality,  but  it  is  certainly  dependent,  to  a  con- 
siderable extent,  on  the  condition  of  society*.  It  is  less  frequent  in  a 
community  in  comfortable  circumstances,  and  engaged  in  wholesome 
and  quiet  occupations.  Pure  air  and  outdoor  exercise,  plain,  nutritious 
diet,  freedom  from  cares  and  anxieties — in  fine,  causes  which  promote 
the  physical  Avell-being,  diminish  the  liability  to  an  ill-formed  and  cya- 
notic offspi'ing.  An(i,  conversely,  impure  air,  improper  and  insufficient 
diet,  grief,  etc.,  increase  the  percentage  of  cyanotic  cases.  Hence,  it  is  a 
rare  disease  in  rural  districts,  and  comparatively  frecjuent  in  cities,  espe- 
cially in  a  large  city  like  New  York,  which  contains  a  numerous  indi- 
gent and  careworn  population,  living  from  year  to  year  in  the  midst  of 
agencies  which  operate  stealthily  but  certainly  to  enervate  the  system 
and  undermine  the  health. 

These  remarks  are  abundantly  substantiated  by  statistics.  In  New 
York  City  for  the  six  years  ending  Avith  1(860,  one  death  resulted  from 
cyanosis  to  43G  deaths  from  all  causes ;  and  in  Brooklyn  the  proportion 
estimated  for  two  years  was  about  the  same.  On  the  other  hand,  in  the 
State  of  Kentucky,  which  contains  few  large  cities,  and  in  the  death 
reports  of  which  cyanosis  is  included  in  the  general  term  malformation, 
there  was,  during  a  period  of  five  years,  one  death  from  malformation 
to  2469  from  all  causes.  In  the  State  of  South  Carolina,  for  three 
years,  one  death  resulted  from  cyanosis  to  501  <S  from  all  causes.  In 
the  State  of  Massachusetts,  for  two  years,  there  was  one  death  from 
cyanosis  to  1136  from  all  causes,  and  two-thirds  of  the  cyanotic  cases 
occurrcfl  in  the  counties  of  Suff'olk,  Essex,  and  Worcester,  which  con- 
tain large  cities.  In  Lond(m  one  death  occurred  from  cyanosis  to  755 
from  all  causes  during  a  period  of  three  years.  On  the  otlicr  liand,  in 
England,  including  the  city  of  London,  there  was,  for  the  ten  years 
ending  with  1857,  one  death  from  cyanosis  to  1589  from  all  causes; 
and  in  the  rural  districts  of  Monmouth  and  Wales  only  one  death 
occurred  from  cyanosis  to  5578  deaths  from  all  causes  during  a  period 
of  two  years. 

Ti.MK  OF  CoMMRXCEMRXT. — It  is  an  interesting  and  somewhat 
remarkable  fact  that  cyanosis,  though  dependent  on  a  malformation, 
docs  not  always  commence  at  birth,  or,  at  least,  that  it  does  not  exist  in 
degree  sufficient  to  ])roduce  the  cyanotic  hue  till  some  tiino  luis  elapwd 
after  birth.  In  13S  of  the  cases  of  cyanosis  which  1  have  collected,  the 
time  at  which  lividity  wa.s  first  observed  is  stated  as  follows:   In  97  it 


828  CYANOSIS, 

was  -within  the  first  week,  and  generally  within  a  few  hours  of  birth. 
In  the  remainin";  41  cases  it  couimeuced  as  follows  : 


In  3  at  2  weeks 

In  G  from  2  3'ears  to 

5  years 

"   1   "  3      " 

"   1      "     5     "       " 

10"   " 

"  2  "  1  month. 

"  6      "   10     "       " 

20     " 

"  7  fruin  1  to    2  months. 

"1      "  20     "       " 

40     " 

"  5     "     2    "     6       " 

"  1  over  40  years. 

"5     "     6    "  12       " 

— 

"3     "     1  year  to  2  years. 

41 

In  these  41  cases,  in  which  hlueness  did  not  occur  till  after  the  age 
of  one  week,  if  the  patient  were  less  than  two  years  old  when  it  com- 
menced there  was  fre<|uently  no  obvious  exciting  cause,  but  above  this 
age,  with  three  exceptions,  such  a  cause  is  known  to  have  been  present. 
It  is  interesting  to  observe  how  trivial  the  exciting  cause  frequently  is, 
and  equally  interesting  to  note  how  long  patients  have  enjoyed  good 
health,  not  having  the  least  lividity,  although  the  anatomical  vice,  to 
which  the  final  development  of  cyanosis  was  due,  had  existed  from 
birth. 

Dr.  Theophilus  Thompson^  relates  the  history  of  a  lady,  thirty-eight 
years  old,  who  was  well  till  an  attack  of  Asiatic  cholera,  after  which 
her  health  was  permanently  impaired.  Two  years  befoie  her  death 
she  passed  through  a  course  of  fever,  and  from  this  time  was  cyanotic. 
Dr.  Waters^  relates  a  case  in  which  cyanosis  began  at  the  age  of  six 
years  in  an  attack  of  measles.  In  a  case  published  by  Mr.  Napper,^ 
the  child  fell  at  the  age  of  six  months,  and  from  this  time  had  cyanosis. 
A  female,  whose  history  is  given  by  Prof  Tommasini,  of  Bologna,  and 
quoted  by  Bouillaud,  became  cyanotic  at  the  age  of  twenty-five  in  con- 
sequence of  difficult  parturition.  Mr.  Stedman''  relates  a  case,  in  which 
cyanosis  began  at  the  age  of  ten  weeks  in  an  attack  of  convulsions. 
Dr.  John  P.  Harrison^  published  the  history  of  a  baker,  twenty  years 
old,  in  whom  cyanosis  began  five  years  previously  after  great  effort  in 
carrying  wood.  Louis  and  Bouillaud  quote  from  M.  Caillot  the  case  of 
a  child,  who  became  cyanotic  at  the  age  of  two  months  in  an  attack  of 
hooping-cough.  Louis  also  narrates  a  case  in  which  hooping-cough 
had  the  same  effect  at  the  age  of  twelve  years.  Ribes  treated  a  child 
in  whom  the  blue  disease  began  at  the  age  of  three  years  from  a  severe 
contusion  of  the  fingers.  In  a  case  related  by  Marx  it  commenced  at 
the  age  of  ten  months  from  a  blow-  on  the  back,  inflicted  by  the  mother. 
Mr.  Speer^  gives  the  history  of  a  female,  who  at  the  age  of  thirteen 
years  was  put  in  a  place  requiring  considerable  exertion,  and  from  this 
time  was  cyanotic.  A  patient,  whose  ca,se  is  related  by  Cherrier,  fell 
into  a  deep  ditch  in  the  Avinter  season,  and  immediately  after  had  a  low 
fever,  from  which  the  blue  disease  commenced.  In  a  case  published  l)y 
Tacconus  the  exciting  cause  was  believed  to  be  fright,  in  consequence  of 
a  fall  from  a  great  height,  and  in  another,  related  by  Bouillaud,  it  was 

'  Mcdico-Chir.  Trans.,  vol.  xxv. 

'^  Philadelphia  Medical  Examiner,  .June,  1850. 

^  London  Medical  Gazette,  1841.  *  London  Lancet,  1842. 

''  Amoriean  Journal  of  Medical  Sciences,  1847. 

8  Medical  Times  and  Gazette,  for  1855. 


SYMPTOMS.  829 

a  blow  received  on  the  epigastrium  after  the  patient  had  passed  the  age 
of  fifty  years.     Siraihir  cases  are  related  by  Mayo  and  Peacock. 

It  will  be  seen  that  the  exciting  cause  of  cyanosis  is  usually  such  as 
produces  a  profound  impression  on  the  system,  and  affects  tiie  action  of 
the  heart.  Precisely  in  what  way  it  operates  to  develop  the  disease  has 
not  been  satisfactorily  explained.  Mr.  Mayo  conjectures,  that  in  the 
case  related  by  him  there  was  previously  some  compensation  which 
ceased,  or  became  inadequate  in  consequence  of  some  change  produced 
in  the  economy.  Although  cyanosis  may  not  appear  for  months  or  even 
years,  there  is  rarely  improvement  when  it  is  once  established.  Appear- 
ances of  amendment  are  deceptive.  The  disease  when  not  stationary  is 
proi^ressive,  and  this  explains  the  fact  that  few  survive  the  middle  period 
of  life. 

Symptoms. — The  symptoms  in  cyanosis  vary  in  intensity  in  different 
patients,  and  in  the  same  patient  at  different  times,  being  milder  if  he  be 
quiet  and  the  mind  calm,  more  severe  if  active,  or  if  the  mind  be  agitated. 
In  mild  cases,  in  a  state  of  rest,  they  nearly  or  (piite  disappear,  so  that 
a  stranger  wouhl  not  suspect  that  there  was  any  serious  aihnent.  They 
are  aggravated  by  any  cause  which  accelerates  the  action  of  the  heart. 
In  some  patients,  cyanosis  is  increased  by  the  most  trivial  disturbing 
influences,  among  which  may  be  mentioned  nursing,  dentition,  crying, 
coushinur,  and  slio-ht  emotions  of  iov,  sorrow,  or  anrjer.  In  more  than 
one  case  it  has  been  perceptibly  increased  by  the  stimulus  of  digestion, 
the  color  being  deeper  after  a  full  meal  than  before. 

The  cyanotic  hue  varies  in  different  individuals  from  duskiness  to  a 
deep  purple,  almost  black  color.  It  is  usually  most  marked  in  the  vis- 
age, especially  the  palpebra?,  cheeks,  nose,  and  lips,  in  the  ears,  fingers, 
ami  toes,  and  upon  the  mucous  surfaces.  It  is  sometimes,  without  any 
assignable  cause,  confined  to  a  ]iortion  of  the  body.  In  a  case  related 
by  Mr.  Steel,^  the  upper  part  of  the  body  was  livid  and  ocdematous,  and 
the  lower  part  pallid  and  shrunken,  and  yet  the  malformation  was  of 
the  kind  which  is  commonly  present  in  cyanosis.  In  the  London 
3Ii'dical  Times,  March  8,  1845,  copied  from  the  G-azctte  Medicale,  is 
the  history  of  a  child  six  years  old,  in  whom  the  color  was  deeper  on  the 
right  than  left  side.  There  had  been,  however,  hemiplegia  of  this  side 
in  infancy,  but  this  hnd  entirely  passed  off.  On  the  other  hand,  in  a 
case  of  rare  malformation  communicated  by  Cooper  to  Farre,  in  which 
the  upper  part  of  the  system  was  supplied  chiefly  by  arterial  and  the 
lower  by  venous  blood,  the  discoloration  was  general.  In  exceptional 
instances  livid  macuUie,  like  those  of  purpura,  have  been  observed  upon 
the  skin. 

Those  affected  with  cyanosis  have  generally  at  birth  1)een  well  formed 
and  of  the  usual  size,  and  in  most  cases,  for  a  considerable  period  after 
birth,  the  appetite  is  good,  bowels  regular,  and  the  system  well  nour- 
ished. But  when  cyanosis  becomes  so  severe,  sis  it  does  sooner  or  later, 
that  its  symptoms  are  rarely  absent,  digestion  is  imperfectly  jx'rformccl. 
and  the  body  i)ecomes  cither  emaciated  or  stunted  and  ))uny.  It  may  be 
stated,  as  a  rule,  that  nutrition  is  in  inverse  proportion  to  the  gravity  ot 

»  London  Lancet,  1838. 


830  CYANOSIS. 

cyanosis.  In  thirty-three  out  of  forty-one  cases,  in  which  the  condition 
of  the  system,  as  regards  nutrition,  was  recorded  either  a  short  time 
previously  to  death  or  at  the  autopsy,  the  body  was  either  considerably 
emaciated  or  else  diminutive,  and  those  who  were  well  nourished  were 
usually  such  as  had  died  early,  or  of  some  intercurrent  disease. 

In  tins  connection  may  be  mentioned  two  abnormalities  which  have 
been  observed  in  the  cyanotic.  The  chest  is  often  flattened  laterally, 
with  a  projecting  sternum,  so  as  to  present  an  appearance  generally 
described  in  the  records  as  "pigeon-breasted."  Sometimes  the  most 
prominent  part  is  directly  over  the  heart,  and  in  one  or  two  cases  the 
sternum  was  observed  to  be  deflected  toward  the  left.  In  the  majority 
of  the  records,  however,  no  mention  is  made  of  the  external  appearance 
of  the  chest. 

The  other  abnormality  is  frequently  observed  in  chronic  diseases  of 
the  heart  and  lungs,  in  which  there  is  sluggish  circulation  and  conse- 
quent altered  nutrition  in  the  fingers  and  toes.  In  twenty-eight  cases 
it  is  stated  that  the  tips  of  the  fingers  or  toes,  or  both,  were  bulbous. 
This  hypertrophy,  if  slight,  is  likely  to  be  overlooked,  and  that  it  was 
observed  and  recorded  in  so  many  cases  renders  it  probable  that  it  was 
present  in  a  much  larger  number.  In  one  case  the  anatomical  char- 
acter of  this  enlargement  Avas  examined,  and  was  found  to  consist  chiefly 
of  hypertrophied  connective  tissue. 

The  nails  are  often  incurvated  over  the  deformity.  At  a  meeting  of 
the  Lond.  Path.  Soc,  in  1850,  Mr.  (.)gle  narrated  the  history  of  a 
laborer,  fifty  years  old,  who  had  SAvelling,  numbness,  and  lividity  of  the 
left  arm,  from  pressure  of  an  aneurism,  and  the  fingers  on  this  side 
were  clubbed  as  in  cyanosis.  A  patient  whose  history  is  related  in  the 
Glasgow  Medical  Journal,  and  who  Avas  believed  to  be  cyanotic  in  con- 
sequence of  a  highly  emphysematous  state  of  the  lungs,  had  a  similar 
development  of  the  tips  of  both  fingers  and  toes. 

An  interesting  feature  in  cyanosis  is  the  low  grade  of  animal  heat. 
The  temperature  of  the  body  is  in  all  cases  beloAv  that  of  health.  This 
is  especially  noticeable  in  the  extremities.  There  has  not  been  a  suffi- 
cient number  of  accurate  thermometric  observations  to  determine  whether 
the  internal  heat  is  usually  reduced.  The  following  only  have  been  re- 
corded: Mr.  Fletcher^  relates  the  history  of  a  young  man,  in  whom  the 
thermometer  placed  in  the  mouth  did  not  rise  a1>ove  80°  Fahrenheit. 
Hodgson  reports  the  case  of  a  man,  twenty-five  years  old,  in  whom  the 
thermometer  placed  under  the  tongue  rose  to  100°,  while  in  his  own 
case  it  Avas  two  or  three  degrees  below  that  term.  In  an  experiment, 
recorded  by  Nasse,  the  instrument  placed  in  the  mouth  fell  little  if  at 
all  below  the  healthy  standard  ;  applied  to  external  parts,  it  stood  at 
about  21°  Reaumur. 

The  lack  of  heat  is  the  source  of  great  discomfort  to  a  cyanotic 
patient.  In  mild  Aveather  he  requires  a  fire  to  keep  him  warm,  or  an 
amount  of  clothing  Avhich  to  others  would  be  intolerable,  and  in  cold 
weather  slight  exposure  strikes  him  Avith  a  chill.  Nor  can  he  increase 
his  heat  by  active  exercise,  since  his  infirmity  disqualifies  him  for  this. 

*  Medico-Chir.  Tran.,  vol.  xxv. 


SYMPTOMS.  831 

Although  the  temperature  of  the  surface  is  so  low,  the  occurrence  of 
perspiration,  sometimes  profuse,  is  mentioned  in  several  of  the  records. 

In  severe  cases  of  cyanosis  the  generative  system  is  imperfectly  de- 
veloped. In  the  female,  menstruation  is  scanty  or  delayed,  and  in  the 
male  signs  of  puberty  are  feebly  manifest.  If  the  disease  be  so  mild 
that  the  symptoms  are  absent  when  the  patient  is  in  a  state  of  repose, 
these  organs  attain  nearly  or  quite  their  normal  development.  The 
catamenia  have  appeared  as  early  as  the  age  of  sixteen  years ;  and  a 
cyanotic  patient  treated  by  Cherrier  had  two  children,  but  they  both 
died  of  scrofulous  affections. 

The  action  of  the  heart  is  necessarily  much  involved.  In  mild  forms 
of  the  disease,  if  the  patient  be  quiet,  this  organ  may  beat  with  consid- 
erable slowness  and  regularity,  but  in  all  cases  exercise  or  excitement, 
which  in  a  state  of  health  would  scarcely  have  any  appreciable  affect  on 
the  pulse,  embarrasses  its  movements,  and  produces  palpitation.  In 
severe  cases  palpitation  is  rarely  absent,  and  the  pulse  is  fre((uent,  feeble, 
and  often  intermittent.  In  a  large  proportion  of  patients  bruits  are  pro- 
duced by  the  irregular  circulation  througli  the  heart. 

The  respiration  corresponds  with  the  action  of  the  heart.  It  is  accel- 
erated in  proportion  to  the  frequency  of  the  pulse.  The  suffering  in 
this  disease  is  largely  due  to  paroxysms  of  palpitation  and  dyspnoea. 
These  occur  sometimes  without  any  apparent  exciting  cause,  and  Avhen 
the  patient  is  quiet,  but  they  arc  commonly  induced  by  those  causes 
which  Ave  have  already  mentioned  as  aggravating  the  symptoms  of 
cyanosis.  They  come  on  suddenly,  and  are  attended  by  increase  of 
lividity,  distention  of  the  jugulars,  and  sometimes  of  the  cutaneous 
veins,  and  by  a  sensation  of  present  suffocation.  They  last  only  a  few 
minutes,  and  are  succeeded  by  great  depression  of  the  vital  jwwers.  In 
infants,  on  account  of  greater  nervous  irritability,  and  feeble  f)ower  of 
endurance,  these  paroxysms  often  end  in  convulsions,  which  occasionally 
are  fatal.      A  cough  is  sometimes  present,  but  is  usually  slight. 

Pain  is  not  a  common  symptom.  Some  of  the  patients  comjilain  occa- 
sionally of  headache,  with  or  without  vertigo,  and  occasionally  also  of 
pain  in  the  chest,  but  it  is  uncertain  to  what  extent  or  whether  these 
symptoms  are  dependent  on  the  cyanotic  disease.  The  secretions  do 
not  appear  to  be  affected,  so  far  as  has  been  ascertained.  The  same 
may  be  .said  of  the  intellectual  and  moral  faculties.  In  a  case  related 
by  Dr.  Chevers,^  the  child  was  even  said  to  be  precocious.  The  mind 
is  capable  of  steady  application  and  acquisition,  as  in  health,  ])rovided 
that  the  emotions  are  not  unduly  exciterl. 

Those  who  are  affected  with  cyanosis  are  liable  to  various  forms  of 
hemorrhage,  but  tliis  liability,  if  we  may  judge  from  recorded  cases,  is 
greater  in  youth  and  adult  life  than  in  infancy.  In  two  cases  blood  was 
vomited,  in  one  passed  by  stool,  in  one  it  escaped  from  the  gums,  in 
two  from  the  mouth,  in  eight  from  the  nostrils,  and  in  sixteen  it  was 
expectorated.  Pulmonary  phthisis  was,  however,  usually  present  in 
these  last  cases.     An  interesting  case  is  related  by  Dr.  Wm.  M.  Voris,' 

'  Lond.  Med.  Gnz.,  vol.  xxxviii. 

»  Western  Jmirtuil  ..f  Medici  no  fur  1829. 


832  CYANOSIS. 

of  a  girl,  nine  rears  old.  in  whom  licraorrliage  occurred  nnder  the  scalp, 
producing  great  tumefaction,  and  nearly  closing  the  eyelids.  An  in- 
cision was  made,  from  which  a  pint  and  a  half  of  dark  blood  escaped, 
and  it  was  estimated  that  more  than  half  a  gallon  was  lost  during  the 
ensuing  two  weeks,  at  the  expiration  of  which  time  the  incision  closed. 
The  patient  recovered  from  the  hemorrhage,  but  not  from  the  cyanosis. 

Toward  the  close  of  life  more  or  less  anasarca  occasionally  occurs, 
especially  around  the  ankles,  sometimes  in  the  eyelids  and  face,  and 
rarely  to  a  certain  extent  over  the  Avhole  body.  In  certain  patients  it 
coexists  with  effusion  in  the  serous  cavities. 

It  is  evident  that  one  who  is  affected  with  the  severe  form  of  cya- 
nosis is  disqualified  for  the  duties  of  active  life.  The  sports  of  child- 
hood and  the  useful  labors  of  mature  years  require  an  exertion  for 
Avhicli  he  is  physically  unfit.  He  has  not  the  ability  even  to  engage  in 
animated  conversation,  for  he  is  overcome  by  emotions,  whether  of  joy 
-  or  sorrow.  He  lives  almost  an  idle  spectator  of  the  world  around  him, 
prevented  by  his  infirmity  from  engaging  in  its  pursuits. 

Intercurrent  diseases,  especially  those  of  childhood,  are  badly  toler- 
ated ;  but  hooping-cough  is  the  one  which  these  patients  are  especi- 
ally ill-fitted  to  endure.  Still,  they  sometimes  pass  safely,  not  only 
through  hooping-cough,  but  through  some  of  the  most  dangerous  febrile 
diseases.  It  is  a  question  of  interest,  but  about  which  little  is  known 
with  certainty,  whether  these  intercurrent  maladies  are  influenced  by 
the  cyanotic  or  venous  condition  of  the  blood.  The  symptoms  of  these 
maladies  are  no  doubt  more  alarming,  mainly  on  account  of  the  embar- 
rassed action  of  the  heart,  and  not  on  account  of  the  state  of  the  blood  ; 
still  it  is  reasonable  to  suppose  that  malignant  and  asthenic  diseases  are 
rendered  worse  by  tke  lack  of  oxygen,  and  excess  of  carbonic  acid  in 
the  circulating  fluid. 

Probably  cyanosis  does  not  furnish  immunity  from  any  other  disease, 
although  this  statement  has  been  made  on  a  high  authority.  Roki- 
tansky  says :  '•'■All  forms  of  cyanosis,  or  ratlicr  all  diseases  of  the  heart, 
great  vessels,  and  lungs,  adapted  to  produce  cyanosis,  in  a  greater  or 
less  degree,  cannot  coexist  ivith  tuberculosis.  Cyanosis  affords  a  com- 
plete protection  against  it,  and  in  this  circumstance  may  be  found  an 
explanation  of  the  immunity  from  tuher'culosis  which  many  conditions 
of  the  system,  apparently  very  different  in  their  character,  afford."^ 
This  opinion  of  the  distinguished  pathologist,  notwithstanding  his  ample 
opportunities  for  observation  and  known  accuracy  as  an  observer,  is  not 
substantiated  by  statistics.  So  far  from  its  being  true,  the  low  degree 
of  vitality  in  cyanosis  appears  to  favor  the  occurrence  of  tubercle.  I 
have  records  of  twenty-six  cases  of  cyanosis  in  which  tuberculosis  was 
also  present,  in  several  of  which  the  lungs  contained  cavities.  This  is 
about  thirteen  per  cent,  of  the  whole  number  in  my  collection — a  large 
proportion,  since  so  many  die  in  early  infancy,  at  which  i)eriod  the 
tubercular  disease  is  not  apt  to  occur.  Cyanosis  appears,  also,  to  favor 
the  development  of  cerebral  diseases,  especially  congestion  and  coma,  as 
will  be  seen  presently, 

•   Uand.  del- Pathol.  Ariat.,  II.  Bd. 


MODE    OF    DEATH.  833 

Progxosis. — This  is  unfavorable.  Most  cyanotic  individuals  die 
young.  The  age  which  they  attain  has  been  made  the  subject  of  sta- 
tistical inquiry  by  Aberle.  He  states  that  in  an  aggregate  of  159  cases, 
57,  or  35  per  cent.,  died  before  the  end  of  the  first  year ;  108,  or  more 
than  two-thirds,  died  before  the  age  of  eleven  years  ;  80  between  the 
ages  of  eleven  and  twenty-five  years;  and  of  the  remaining  21,  only  5 
lived  more  than  forty-five  years. 

The  age  at  which  death  occurred,  is  given,  in  186  of  the  cases  col- 
lected by  myself,  as  follows  : 

In  17  under  the  n^e  of  1  week.  In  21  from    5  years  to  10  years. 

"  10  from  1  week  to  1  month.  "  41      *'      lO'    "      "  20      " 

"  12     "      1  month  to  3  months.  "  20     "     20     "      "  40      " 

"  11     "      3  months  to  6  months.  "     4  over  40      " 

"  17     "      6       "      to  12        "  

"   12     "      1  year  to  2  years.  186 

"21     "      2  years  to  o    " 

Sixty-seven,  then,  or  more  than  one-third,  died  before  the  close  of  the 
first  year;  121,  or  more  than  three-fifths,  before  the  age  of  ten  years; 
only  24  survived  the  age  of  twenty  years,  and  4  the  age  of  forty 
years.  Of  course,  the  duration  of  life  depends  on  the  nature  and  extent 
of  the  malformations.  Some  of  these  are  such  as  to  render  a  speedy 
death  inevitable. 

Mode  of  Death. — The  mode  of  death  is  recorded  in  ninety-five 
cases,  as  follows : 

19  died  in  a  paroxysm  of  dyspnoea. 

10  "  suddenly  (the  exart  manner  not  stated). 

14  "  in  convulsions  (infants), 

2  "  of  apoplexy. 

7  "  from  iiemorrhage. 

0  "  of  phthisis  (thouijh,  as  we  have  seen,  twenty  others  had  this  disease). 

2  "  of  exhaustion,  without  hemorrhage. 

10  "  of  coma. 

2  "  of  abscesses  in  the  brain. 

One  died  of  each  of  the  following  diseases :  cerebral  irritation,  con- 
gestion of  brain,  effusion  in  the.  cranial  cavity,  acute  hydrocephalus, 
paralysis  from  acute  softening  of  the  brain,  dysentery,  inflammation  of 
heart,  syncope,  mucus  in  the  air-passages,  thoracic  inflammation,  chole- 
raic diarrhoea,  pneumonitis,  broncliitis,  scarlet  fever,  croup.  One  <lied 
in  trying  to  walk,  one  after  a  spasmodic  cough  in  pertussis,  one  after  a 
long  agony,  one  after  an  agony  often  or  eleven  hours;  one  is  recorded 
to  have  died  gradually,  and  three  quietly. 

The  ten  who  are  stated  to  have  died  suddenly  probably  died  in  parox- 
ysms of  palpitation  and  dyspncea,  which,  we  have  seen,  are  easily  excited, 
and  of  common  occurrence  in  cyanosis.  If  so,  this  was  the  mode  of 
death  in  29  cases.  Infants,  with  few  exceptions,  so  fiir  as  njijx'ars  from 
the  records,  died  in  convulsions.  Nineteen  died  of  cerebral  afl"ections, 
exclusive  of  convulsions,  and  in  thirteen  of  these  the  cau.se  of  death  was 
congestion,  apoplexy,  or  coma.  The  hemorrhnge  of  which  seven  died 
was  probably,  in  most  instances,  dependent  on  phtiiisis,  and  six  are  said 
to  have  died  directly  of  phthisis.     We  may,  then,  regard  paro.xysma  of 

63 


834  CYANOSIS. 

palpitation  and  dyspnoea,  convulsions,  congestive  affections  of  the  brain, 
and  j)hthisis,  as  common  modes  or  causes  of  death  in  cyanosis. 

The  malformations  of  the  heart  and  great  vessels  which  give  rise  to 
cyanosis  are  quite  numerous.  The  following  table  exhibits  their  charac- 
ter and  relative  frequency : 

Cases. 

1.  Pulmonary  artery  absent,  rudimentary,  impervious,  or  partially  obstructed  97 

2.  Kiijlit  auriculo-ventricular  orifice  impervious  or  cotitrncled  ....     5 

3.  Orifice  of  the  pulmonary  artery,  and  the  right  auriculo- ventricular  aperture 

impervious  or  contracted    ..........     6 

4.  Right  ventricle  divided  into  two  cavities  by  a  supernumerary  septum  .         .  11 

5.  One  auricle  and  one  ventricle 12 

6.  Two  auricles  and  one  ventricle       .........     4 

7.  A  single  auriculo-ventricular  opening;  interauricular  and  interventricular 

septa  incomplete  ...........     1 

8.  >Iitral  orifice  closed  or  contracted  .         ........     3 

9.  A.)rta  absent,  rudimentary,  impervious,  or  partially  obstructed    .         ,  ,    S 

10.  Aortic  and  left  auriculo-ventricuhir  orifices  im{)ervious  or  contracted  .         .  1 

11.  Aorta  and  pulmonary  artery  transposed         .......  14 

12.  The  caviB  entering  the  left  auricle          ........  1 

13.  Pulmonary  veins  opening  into  the  right  auricle  or  into  the  cavse  or  azygos 

veins  ..............     2 

14.  Aorta  impervious  or  contracted  above  its  ]inint  of  union  with  the  ductus 

arteriosus,  pulmonary  artery  wholly  or  in  )iart  supplying  blood  to  the 
descending  aorta  through  the  ductus  arteriosus  .....     2 

Total 162 

From  the  above  table  it  appears  that  in  more  than  one-half  of  the 
cases  of  cyanosis  the  congenital  vice  which  gives  rise  to  it  is  located  in  the 
pulmonary  artery.  It  is  located  also,  in  general,  in  that  part  of  the 
artery  which  is  nearest  the  heart.  Its  character  is  different  in  different 
cases.  Sometimes  there  is  an  arrested  development  of  this  vessel,  and 
in  its  place  Ave  find  simply  a  ligamentous  cord  extending  from  the  heart 
as  far  as  the  ductus  arteriosus,  while  beyond  this  })oint  the  artery  and 
its  branches  are  pervious;  rarely  the  entire  artery  is  ligamentous,  and 
of  course  impervious;  in  other  cases  this  vessel  is  open  through  its 
whole  extent,  but  the  part  nearest  the  heart  is  so  small  as  to  be  pro- 
perly considered  rudimentary;  in  others  still,  there  is  adhesion  of  the 
valves  to  each  other  as  the  chief  congenital  defect,  and,  finally,  in  rare 
instances  the  obstruction  in  the  pulmonary  artery  is  due  to  an  adventi- 
tious membrane,  which  stretches  across  the  vessel  like  a  diaphragm. 
These  last  malformations,  namely,  adhesion  of  the  valves  and  the  for- 
mation of  an  adventitious  membrane,  are  doubtless  due  to  inflammation 
occui-ring  in  the  artery  before  birth,  and  some  attribute  the  arrested 
development  and  ligamentous  state  of  the  vessel  to  the  same  cause. 

In  most  cases  of  cyanosis,  due  to  obstructive  malformations,  the  in- 
terauricular and  interventricular  septa  are  more  or  less  deficient.  This 
deficiency  obviously  results  from  the  obstruction,  for  the  septa  are  formed 
in  the  heart  after  fretal  circulation  is  established,  and  the  blood,  being 
prevented  by  the  vicious  formation  from  flowing  in  its  proper  channel, 
necessarily  passes  to  the  opposite  side  of  the  heart.  More  or  less  blood 
being  forced  from  one  auricle  or  one  ventricle  to  the  opposite  cavity,  it 
is  evident  that  a  permanent  aperture  must  result  in  the  septum.     The 


MORBID    ANATOMY.  835 

aperture  in  the  septum  ventriculorum  is  ordinarily  at  its  base ;  in  the 
septum  aurieulorum  it  corresponds  with  the  foramen  ovale. 

In  most  of  the  obstructive  malformations  one  and  rarely  two  abnormal 
cardiac  murmurs  have  been  observed.  The  single  murmur  accompanies 
the  ventricular  contraction.  As  it  has  been  observed  in  cases  of  com- 
plete as  Avell  as  incomplete  obstruction,  it  seems  to  be  due  mainlv  to  the 
flow  of  blood  through  the  apertures  in  the  septa. 

Modes  of  Compensatiox. — In  most  cases  of  cyanosis  the  congenital 
defect  is  partially  obviated  by  modes  of  compensation.  In  the  most  fre- 
quent malformation,  that  in  which  there  is  obstruction  in  the  pulmo- 
nary artery,  and  a  considerable  part  if  not  all  the  blood  flows  directly 
from  the  right  to  the  left  side  of  the  heart,  the  ductus  arteriosus  not 
only  remains  open,  but  is  greatly  enlarged,  through  which  a  current 
of  blood  enters  the  pulmonary  artery  from  the  aorta,  and  passing  to  the 
lungs  is  oxygenated.  The  bronchial  arteries  have  also  been  f<iund 
greatly  enlarged,  and  it  is  believed  that  though  they  are  the  nutrient 
arteries  of  the  lungs,  the  blood  which  they  convey  to  these  organs  is 
decarbonized  in  its  circuit  through  them.  In  a  case  published  by  Mr. 
Le  Gros  Clark, ^  the  b-ronchial  arteries  were  not  only  enlarged,  but  a 
"  branch  from  the  internal  mammary  artery,  which  accompanied  the 
phrenic  nerve,  was  nearly  equal  in  size  to  the  parent  trunk,  and  ex- 
pended itself  principally  in  the  adjacent  adherent  lung."  ]>ranches  of 
the  intercostal  arteries  have  also  been  found  enlarged,  and  entering  the 
lungs,  or  connecting  with  vessels  which  enter  the  lungs.  By  such 
modes  of  compensation  cyanosis  is  rendered  milder,  and  life  is  pro- 
longed. To  these  we  must  attribute  the  fact  that  some  have  very  con- 
siderable malformation,  and  yet  do  not  become  cyanotic. 

Morbid  Anato:\iy. — This,  as  regards  the  circulatory  system,  has 
been  sufficiently  dwelt  upon.  No  chemical  analysis,  so  far  as  I  am 
aware,  has  yet  been  marie  of  cyanotic  blood.  We  know  that  it  is  dark, 
its  coagulability  feeble,  that  it  contains  an  excess  of  carbonic  acid,  and 
is  deficient  in  oxA'gen.  From  the  nature  of  cyanosis,  it  would  be  in- 
ferred that  in  many  cases  there  is  a  degree  of  passive  congestion  in  the 
cavities  of  the  hciirt,  and  consequently  in  the  capillaries  of  the  general 
system,  giving  rise  to  more  or  less  serous  efl'usion.  Statistics  show  that 
this  is  so.  The  quantity  of  pericardial  ihiid  is  in  some  patients  in- 
creased. I  have  records  relating  to  this  fluid  in  fifty-one  cases.  Usually 
it  was  pure  serum.  In  seventeen  the  quantity  was  half  an  ounce  or 
less,  if  we  include  in  the  number  those  in  which  the  amount  is  expressed 
in  such  terms  as  "  due  quantity,"  "  usual  amount,"  and  "small  amount." 
In  twenty-four  cases  the  pericardial  fluid  (serum)  exceeded  half  an 
ounce,  usually  estimated  at  from  one  to  six  ounces,  but  in  two  it  ex- 
ceeded the  latter  ([uantity.  It  one  of  the  twenty-four  this  fluid  was 
stained  with  blood.  In  two  patients  the  records  state  that  there  was  a 
small  quantity  of  pure  bh)od  in  the  pericardium,  and  in  one  the  two 
pericardial  surfaces  were  agglutinated  by  inflamuiation. 

In  some  of  the  autopsies  serum  was  found  in  the  pleui-al  cavities, 
usuallv  in  connection  with  pericardial  (effusion,  and  in  at  least  one  in- 

'  Medico-Chir.  Trans.,  vol.  xxx. 


836  CYANOSIS. 

stance  this  fluid  was  tinged  "with  blood.  Old  adhesions  between  the 
costal  and  pulmonary  pleura,  were  observed  in  a  few  instances.  The 
condition  of  the  lungs  was  recorded  with  more  or  less  minuteness  in  one 
hundred  and  ten  cases.  Mention  has  already  been  made  of  tlie  large 
number  afiected  with  tubercular  disease,  which  Avas  either  confined  to 
the  lungs,  or  was  chiefly  exhibited  in  these  organs.  In  thirty-five 
patients  the  records  state  that  the  lungs  were  of  small  size,  either  by 
compression,  or  sometimes,  apparently,  from  tlie  continuance  of  the  foetal 
state  over  a  greater  or  less  portion  of  the  organ.  The  compression  was 
produced  either  by  the  distended  pericardium  or  by  efiusion  in  the 
pleural  cavities.  In  thirty-five  cases  the  lungs  presented  a  dark  color. 
This  hue  in  some  specimens  accompanied  the  unexpanded  or  f(jctal  state 
of  the  organ,  but  in  others  there  w^as  the  normal  inflation,  and  the  dark 
color  was  due  to  engorgement  or  congestion.  In  otber  cases  the  lungs 
are  stated  to  have  been  natural,  except  the  color.  In  nine  emphysema 
was  present  in  a  part  of  the  lungs,  in  two  pneumonitis;  in  two  the  color 
of  the  lungs  was  pale,  in  one  a  bright  crimson  ;  in  one  the  lungs  were 
larger  than  natural,  in  one  the  right  lung  was  absent,  and  in  seventeen 
these  organs  were  recorded  healthy. 

I  have  records  of  the  state  of  the  liver  in  twenty-six  cases,  in  sixteen 
of  which  it  was  enlaro;ed,  and  in  four  of  these  it  was  concjested.  Con- 
gestion  of  the  liver  was  present  in  eight  other  cases,  in  which  no  mention 
is  made  of  its  volume.  The  parenchyma  of  this  organ  had  a  natural 
appearance  in  nine  cases,  but  in  some  of  these  there  was  enlargement. 
From  tliese  statistics  it  is  probable  that  the  liver  is  commonl}?  enlarged 
in  cyanosis,  and  not  infrequently  congested.  In  a  few  cases  the  condi- 
tion of  the  other  abdominal  viscera  is  mentioned  ;  in  some  as  healthy,  in 
others  as  congested.  Fifteen  examinations  of  the  brain  were  made,  in 
seven  of  which  congestion  is  recorded,  and  in  three  abscesses  in  the 
cerebral  substance,  in  one  of  Avliich  cases  the  lateral  ventricle  was  also 
filled  with  pus  ;  in  two  softening  of  a  portion  of  the  brain  had  occurred, 
in  three  the  brain  Avas  firm  or  compact,  in  three  the  quantity  of  fluid  in 
the  cranial  cavity  exceeded  the  normal  amount,  and  in  one  it  Avas  less 
than  normal. 

Theories  Relating  to  the  Etiology  of  Cyanosis. — Although  in 
nearly  all  cyanotic  patients  there  are  direct  communications  betAveen  the 
tAvo  sides  of  the  heart,  it  is  shoAvn  by  many  obserA^ations  that  these  com- 
munications or  apertures  are  not  sufficient  in  themselves  to  produce 
cyanosis.  This  opinion  Avas  expressed  half  a  century  ago  by  Louis,  Avho 
published  an  excellent  monograph  on  the  subject  of  these  communica- 
tions, basing  his  remarks  on  an  analysis  of  tAventy  cases.  Since  the 
publication  of  this  paper,  the  belief  has  been  pretty  general  in  the  pro- 
fession, and  observations  continue  to  substantiate  it,  that,  although  the 
apertures  may  be  of  considerable  size,  if  the  two  sides  of  the  heart,  Avith 
their  orifices  and  vessels,  are  in  their  normal  state,  so  that  they  act 
symmetrically  and  Avithout  obstruction,  cyanosis  does  not  occur.  In 
proof  of  the  correctness  of  this  opinion  many  cases  might  be  cited  of  a 
pervious,  and  some  of  a  largely  dilated  foramen  ovale,  without  the 
cyanotic  hue,  cases  Avhich  have  been  published  in  the  journals  since  the 
appearance  of  Louis's  monograph.     Still,  in  cases  of  obstructive  mal- 


ETIOLOGY    OF    CYAXOSIS.  837 

formation,  unless  the  obstruction  be  complete,  cyanosis  is  more  likely  to 
occur  in  consequence  of  these  apertures,  for  were  they  absent  a  larger 
amount  of  blood  would  be  propeUed  through  the  narrowed  orifice,  and  a 
larger  amount  consequently  be  oxygenated. 

Allusion  has  already  been  made  to  the  two  theories  which  prevail  in 
the  profession;  oneattributing  cyanosis  to  the  intermingling  of  venous 
and  arterial  blood ;  the  other  to  obstruction  at  the  centre  of  circula- 
tion, and  consequent  venous  congestion.  There  are  serious  objections  to 
the  acceptance  of  either  theory  as  an  explanation  for  all  cases.  That  ad- 
mixture of  the  two  kinds  of  blood  is  not  essential  to  the  production  of 
cyanosis,  is  apparent  from  the  following  facts.  In  one  case  in  the  Fourth 
Malformation,  there  was  no  communication  between  the  two  sides  of  the 
heart,  and  the  ductus  arteriosus  was  closed,  so  that  admixture  was  im- 
possible. Again,  in  the  Eleventh  Malformation,  or  that  in  which  the 
aorta  and  pulmonary  artery  are  transposed,  the  blue  disease  evidently 
does  not  depend  on  the  admixture  of  the  two  currents.  On  the  other 
hand,  in  this  curious  state  of  the  heart,  the  more  the  admixture  the  less 
the  cyanosis,  since  the  only  way  in  which  the  systemic  current  of  blood 
can  be  arterialized  is  by  passing  to  the  opposite  side  of  the  heart.  An 
argument  against  this  doctrine  may  also  be  found  in  the  ftict  that  the 
modes  of  compensation  are  not  such  as  in  any  way  diminish  or  obviate 
the  admixture.  It  is  admitted  that  in  the  more  frequent  malformations 
cyanosis  is  increased  by  the  apertures,  which  allow  the  intermingling 
of  the  venous  and  arterial  currents,  but  it  is  more  reasonable  to  consider 
the  intermingling  and  the  cyanosis  as  the  direct  results  of  the  malfor- 
mation, neither  having  precedence  of  the  other,  than  to  consider  that 
they  are  related  to  each  other  as  cause  and  effect,  or  as  proximate  and 
remote  results.  Viewed  in  this  light,  the  admixture  must  be  considered 
simply  a  concomitant  of  the  cyanosis. 

The  second  theory,  that  of  venous  congestion,  has  numbered  among 
its  advocates  many  who  have  given  special  attention  to  the  subject,  as 
Morgagni,  Louis,  and  Stille,  but  it  seems  to  have  even  less  claim  for 
acceptance  than  the  theory  of  admixtuie.  It  has  been  seen  that  in 
nearly  all  cases  of  cyanosis  the  two  sides  of  the  heart  communicate  freely. 
80  that  if  the  current  of  blood  meet  with  an  obstruction,  as  it  commonly 
does,  it  readily  escapes  to  the  opposite  side  where  the  artery  is  large 
and  gives  it  free  passage.  In  this  way  congestion,  if  not  ])revent('(l,  is 
greatly  diminished.  Again,  it  will  be  seen  that,  although  certain  of  the 
viscera  are  ftxMjuently  found  at  the  autopsy  more  or  less  congested,  con- 
gestion is  not  uniformly  present  in  the  organs,  as  it  would  probably  be 
were  it  the  proximate  cause  in  all  cases  of  cyanosis. 

Moreover,  in  some  patients  the  malformation  is  not  obstructive.  The 
cavities  and  their  orifices  are  of  the  normal  size,  and  cyan<»sis  is  due 
entirely  to  malposition  of  the  vessels.  It  cannot  be  said  that  in  these 
cases  there  is  venous  congcstictn  from  arrest  at  the  centre  of  circulation. 
If  there  be  any  congestion,  it  must  be  due  to  the  fact  that  venous  blood 
does  not  circulate  as  readily  as  the  arterial  in  the  capillaries.  It  is  true 
that  jn  the  paroxysms  of  dyspmica  there  is  sometimes  more  or  less  con- 
gestion; the  distention  of  the  jugulars  shows  this,  but  it  subsides  with 


838  CYANOSIS. 

the  paroxysms,  and  it  probably  is  no  more  than  usually  occurs  when  the 
respiration  is  greatly  embarrassed. 

In  fine,  attempts  to  express  the  immediate  pathological  state  pro- 
ducing cyanosis  in  the  terms  of  a  general  law  have  foiled.  However 
plausible  the  above  tlieories  may  appear  in  regard  to  certain  cases,  there 
are  others  to  which  they  are  manifestly  inapplicable.  Those  who  advo- 
cate these  theories  seem  to  lose  sight  of  the  obvious  fact  that  the  chief 
want  of  the  economy  in  cyanosis  is  decarbonization  of  the  blood,  and  it 
is  hardly  supposable  that  there  can  be  any  correct  theory  of  its  causa- 
tion which  is  not  founded  on  this  fact.  With  this  physiological  state  in 
view,  it  does  not  seem  difficult  to  express  a  theory  in  comprehensive 
terms  which  is  applicable  to  all  cases,  such  as  the  following :  Cyanosis 
is  due  to  vices  or  defects  in  the  on/aiiism,  usiiaUt/  eonf/enital,  tvldch 
prevent  the  free  and  regular  flew  of  blood  to,  tlirouyh,  or  from  the  lungs. 
So  comprehensive  a  statement  includes  not  only  cases  of  malformation 
and  malposition  of  the  heart  and  its  vessels,  but  also  those  few  cases  in 
which  the  lungs  are  in  fault.  In  most  patients,  as  we  have  seen,  the 
current  of  blood  toward  the  lungs  is  obstructed,  and  the  current  of  blood 
from  the  lungs,  in  those  comparatively  rare  cases  in  which  the  malfor- 
mation is  on  the  left  side. 

Treatment. — From  the  nature  of  cyanosis  it  is  evident  that  the  treat- 
ment should  be  more  hygienic  than  medicinal.  The  patient  should  be 
w^armly  clad  and  kept  in  a  warm  room,  and  all  agencies  calculated  to 
embarrass  or  disturb  the  functions  of  the  body  or  excite  the  emotions, 
and  thereby  accelerate  the  heart's  action,  should  be  studiously  avoided. 
The  diet  should  be  nutritious,  but  simple  and  easily  digested. 

Those  who  have  attributed  cyanosis  wholly  to  apertures  in  the  inter- 
auricular  and  inter-ventricular  septa,  and  the  consequent  flow  of  blood 
from  the  right  to  the  left  side  of  the  heart,  have  considered  it  an  impor- 
tant part  of  the  treatment  to  keep  the  patient  reclining  on  the  right  side, 
so  as  to  diminish  this  flow  by  the  effect  of  gravitation.  The  reader, 
however,  must  be  convinced  from  the  nature  of  the  malformations  that 
little  benefit  can  accrue  from  following  such  advice.  Still,  patients  are 
sometimes  less  cyanotic  and  more  comfortable  in  one  position  than 
another.  In  a  case  reported  by  Mr.  Ilowship,^  "the  only  easy  and 
indeed  comfortable  position  in  which  the  child  could  remain  was  that 
usual  in  nursing.  When  erect,  the  dusky  color  of  the  face  and  neck 
became  a  dark  blue."  In  a  case  related  by  Mr.  Spackman,^  the  patient 
was  easiest  on  the  hands  and  knees.  Louis ^  reports  a  case  in  which  the 
selected  position  was  with  the  head  elevated;  Wm.  Hunter,*  a  case  in 
which  the  patient  avoided  paroxysms  by  lying  on  the  left  side.  Struthers 
and  King^  each  report  a  case  in  which  the  patients  seemed  most  com- 
fortable while  lying  on  the  right  side;  while,  on  the  other  hand.  Pro- 
fessor White,*  of  Buffixlo,  and  Dr.  Jas.  Carson,'  report  cases  in  which 
position  on  the  right  side  failed  to  produce  any  alleviation  of  symptoms. 
Other  similar  observations  might  be  cited,  but  enough  have  been  men- 

»  Edin.  Med,  .Tourn.,  1813.  «  Lond.  Med.  Gaz  ,  1833. 

'  De  Irt  Coiiinmii.  des  Cav.,  otc.  *   Med.  01)-.  and  Enq.,  vol.  vi. 

6  Monthly  Journ.  of  Med.  Sci.  ^  Bull".  Med.  Journ.,  1855. 
'  Amer.  Journ,  of  Med.  Sci  ,  1857. 


TREATMENT.  839 

tioned  to  show  that  no  one  position  should  be  recommended  for  cyanotic 
patients.  Some  obtain  most  relief  by  lying  on  the  back,  others  on  the 
right  side,  others  on  the  left,  some  when  on  the  hands  and  knees,  some 
when  reclining  on  either  side  indifferently,  while,  finally,  others  suffer 
least  when  erect. 

There  was  a  time  when  the  paroxysms  were  treated  by  venesection, 
but  depletion  has  long  since  been  abandoned.  Physicians  now  rely  on 
stimulants,  antispasmodics,  friction  to  the  chest,  and  mustard  pediluvia, 
to  relieve  the  urgent  symptoms,  although  this  treatment  is  but  partially 
successful.  It  is  probable  that  of  all  internal  remedies  digitalis  is  the 
most  useful,  from  the  fact  that  it  is  an  efficient  heart  tonic,  and  more 
than  any  other  medicine  gives  strength  and  equality  to  the  heart  beats. 
In  cities,  where  oxygen  gas  can  be  procured  for  daily  inhalation,  it 
seems  not  improbable  that  the  urgent  symptoms  may  in  some  instances 
be  partially  relieved  by  the  use  of  this  agent. 


SECTION  YI. 

SKIN  DISEASES. 


CHAPTER  I. 

EKYTHEMATOUS  DISEASES. 

Under  this  head  are  induded  ei-ythema,  roseola,  and  urticaria.  They 
consist  in  an  active  congestion,  inflammatory  it  is  believed,  of  the  skin, 
which  soon  declines,  with  or  without  slight  furfuraceous  desquamation. 
The  color  of  the  affected  cuticle  is  bright  red  m  erythema,  rosy  in 
roseola,  and  pale  red  in  urticaria.  Febrile  symptoms  often  precede  for 
a  few  hours  the  occurrence  of  the  eruption,  and  they  abate  as  it  appears. 

Erythema. 

The  eruption  of  erythema  occurs  in  patches  of  different  sizes,  the 
largest  ordinarily  not  exceeding  four  or  five  inches  in  length,  and  most 
of  them  have  considerably  smaller  dimensions,  their  margins  being  in 
some  instances  diffused,  and  in  others  circumscribed  and  well  defined. 
The  patches  are  slightly  swollen  from  engorgement  of  the  capillaries  of 
the  skin  and  slight  serous  effusion,  and  are  accompanied  by  a  sensation 
of  heat  and  itching. 

Erythema  is  idiopathic  or  symptomatic.  The  idiopathic  form  is  sub- 
divided into  erythema  simplex,  intertrigo,  and  hieve.  Erythema  sim- 
plex is  produced  by  external  agencies  of  an  irritating  nature,  as  heat, 
cold,  friction,  chemical  and  mechanical  irritants,  applied  to  the  skin.  A 
common  example  of  this  form  of  the  disease  is  the  efflorescence  about 
the  anus  in  cases  of  infantile  diarrhoea  due  to  acidity  of  the  evacuations. 
Erythema  intertrigo  is  produced  by  the  friction  of  opuosing  surfaces  of 
the  skin,  and  it  therefore  occurs  mainly  in  the  folds  of  the  neck,  about 
the  groins,  and  behind  the  ears.  This  inflammation  is  sometimes  slight, 
disappearing  in  two  or  three  days  Avith  proper  treatment;  in  other  cases 
the  epidermis  becomes  denuded,  the  surface  is  tender  and  moist,  and 
even  superficial  excoriations  occur.  In  severe  cases  the  ulcers  extend 
more  deeply  and  give  rise  to  considerable  purulent  discharge,  the  skin 
and  even  subcutaneous  connective  tissue  being  more  or  less  infiltrated 
and  indurated.  The  confinement  of  the  perspiration,  and  the  moisture, 
(840) 


DIAGNOSIS.  841 

■which  is  exuded  between  the  folds  of  the  skin,  increase  the  inflammation. 
The  effused  liquid  does  not  in  ordinary  cases  stiffen  linen,  as  in  eczema. 
Erythema  laeve  is  the  name  applied  to  the  inflammatory  hyperemia  of 
the  skin,  which  often  occurs  over  cedematous  parts.  Its  most  common 
seat  is  about  the  ankles  and  upon  the  legs.  In  children  it  is  most  fre- 
quently observed  in  the  oedema  which  results  from  scarlatinous  nephritis 
and  from  heart  disease. 

Sytnptoinatic  erythema,  which  results  from  a  general  or  constitutional 
cause  of  a  pyrexial  cliaracter,  has  several  subdivisions.  The  simplest 
and  mildest  form  of  it  is  erythema  fugax,  which  comes  and  goes  quickly. 
The  erythema  which  occurs  upon  the  features  in  acute  meningitis  is  a 
typical  example.  It  is  common  in  various  inflammatory  and  febrile 
affections.  If  the  erythematous  patch  be  circular,  with  normal  skin  in 
its  centre,  it  is  sometimes  designated  erythema  circinatum,  and,  if  the 
margin  be  well  defined,  marginatum.  Erythema  papulatum,  tubercu- 
latum, and  nodosum  are  applied  to  the  same  form  of  the  disease,  one  or 
the  other  term  being  employed  according  to  the  stage  or  size  of  the 
eruption.  In  erythema  papulatum  the  eruption  begins  as  small  red 
spots,  which  soon  become  papular,  and  attain  a  size  varying  from  that 
of  a  pin's  head  to  a  split  pea.  It  occurs  especially  on  the  neck,  breast, 
arm,  and  back  of  the  hand,  and  fades  away,  with  a  slight  desquamation, 
in  about  three  weeks.  In  erythema  tuberculatum  and  nodosum  the 
eruptions  have  a  greater  diameter,  and  are  u;ually  more  ])rominent.  In 
the  hitter  variety  they  often  have  a  diameter  of  two  or  more  inches,  and 
occur  most  frequently  upon  tlie  anterior  aspect  of  the  leg.  These  three 
forms  of  erythema,  which  may  be  described  as  one,  occur  chiefly  in 
young  people.  Erythema  tuberculatum  is  most  common  in  servants, 
especially  those  recently  from  the  country.  The  tumefaction  is  due  to 
the  eftVision  of  serum  in  the  corium,  and,  when  the  eruption  has  con- 
siderable })r(>minence,  also  in  the  subcutaneous  connective  tissue.  The 
color  is  at  first  a  bright  red,  then  dark  red  or  purple,  and  it  fades  away 
like  the  discoloration  of  a  bruise  as  the  eruption  declines.  Rheumatism 
is  often  and  diarrhcea  occasionally  associated  with  these  forms  of  ery- 
thema, and  rheumatic  pains  are  occasionally  present,  as  well  as  more 
or  less  febrile  movement. 

Prognosis. — This,  as  regards  the  erythema,  is  always  good.  An 
unfavorable  result  in  any  ease  is  due  to  cachexia,  or  some  coexisting 
disease.  The  duration  of  the  milder  cases  is  only  a  few  hours,  while 
cases  of  a  more  severe  type,  as  erythema  nodosum,  last  two  or  three 
weeks. 

DlAfiNOSis. — The  ordinary  forms  of  erythema  are  distinguished  from 
erysipelas,  by  the  absence  of  any  very  decided  burning  pain,  and  tume- 
faction of  the  integument,  and  tendency  to  spread,  and  by  less  nuirked 
constitutional  symptoms.  In  those  cases  of  erythema  in  wliich  there  are 
infiltration  and  swelling  of  the  skin  and  subcutaneous  connective  tissue, 
the  patches  are  distinguished  from  those  of  erysipelas  by  being  nndtiple, 
of  smaller  size,  less  hot  and  painful,  not  extending,  and  presenting  as 
they  disa[)pear  the  ])henomena  of  a  bruise.  In  urticaria  the  wheals 
that  come  and  go  siulderdy  with  a  peculiar  stinging  sensation,  and  the 
irritability  of  the  skin  in  consequence  of  which  these  wheals  are  jtro- 


842  ERYTHEMA. 

duced  by  slight  friction,  differ  so  much  from  the  symptoms  and  appear- 
ances of  erythema  that  the  differential  diagnosis  of  the  two  is  easy.  In 
roseola  the  eruption  ordinarily  occurs  over  a  large  jiart,  if  not  the  entire 
surface,  in  points  and  small  patches  with  healthy  skin  between,  and  pre- 
senting a  rosy  instead  of  a  bright  red  color,  characters  which  sufficiently 
distinguish  it  from  erythema.  Erythema  when  extensive  is  sometimes 
mistaken  for  the  scarlatinous  eruption,  but  the  redness  of  the  fauces, 
graver  constitutional  symptoms,  vomiting,  persistence  of  the  eruption, 
etc.,  serve  to  distinguish  the  latter  from  the  former  affection.  In  cases 
of  doubt  it  is  proper  to  defer  the  diagnosis  for  a  day  or  two,  when  if  the 
rash  be  erythematous  it  will  fade.  Erythema  sometimes  occurs  in  the 
initial  stage  of  variola,  when,  on  account  of  the  grave  general  symptoms, 
it  may  be  mistaken  for  scarlatina.  I  have  more  than  once  known  this 
mistake  to  be  made  in  the  hurried  visit  of  the  physician.  A  more  care- 
ful examination  would  prevent  this  error.  There  is  little  danger  of  con- 
founding erythema  with  measles,  or  the  various  papular,  vesicular,  or 
pustular  skin  diseases. 

Treatment. — Erythema  fugax  requires  no  special  treatment,  unless 
occasional  dusting  the  surfice  with  lycopodium  or  powdered  starch. 
Those  forms  of  erythema  which  are  due  to  mechanical  or  chemical  irri- 
tants soon  disappear  when  the  cause  is  removed.  In  erythema  around 
the  anus,  produced  by  the  irritation  of  the  urinary  and  alvine  evacua- 
tions, the  diaper  should  be  changed  as  soon  as  soiled,  and  if  the  stools 
be  frequent  and  acid,  the  alkaline  treatment  proper  for  the  diarrhoea  is 
useful  also  for  the  erythema.  In  inflammation  from  this  cause  as  well 
as  in  erythema  intertrigo,  the  following  prescriptions  for  external  use 
will  be  found  beneficial : 

R. — Bismuthi  subnitrat. ^J- 

Glyceriti  amyli 5J. — Misce. 

B. — Lycopodii    ........      ^ss. 

Pulv.  bismuthi  subnitratis  ....      3iss. — Misee. 

R. — Pulv.  zinc,  oxid., 

Lycopodii aa  ^j. — Misce. 

To  be  frequently  dusted  upon  tbe  inflamed  surface.  It  is  better  to  apply  vaseline 
first,  and  dust  upon  this. 

R. — Zinci  oxid. ^ij. 

Glycerinae  .         .         .         .         .         .         .         •  S'j- 

Liq.  plumb,  subacetatis       .....  S'^s. 

Aquse  calcis ^vjtoviij. — Misce. 

In  obstinate  cases  a  weak  solution  of  nitrate  of  silver,  sulphate  of  cop- 
per, or  better,  as  it  does  not  stain  the  linen,  sulphate  of  zinc,  will  fre- 
quently be  followed  by  immediate  improvement. 

R. — Zinci  sulphat P''- vj. 

Glycerina)  .         .         .         .         .         .         .         •     J'J" 

Aq.  rosio    ........     3'^. — Misce. 

To  be  constantly  applied  between  the  folds  of  the  skin  on  linen. 

Potassium  chlorate,  internally,  to  correct  the  acidity  of  the  transpira- 
tion from  the  skin  in  protracted  and  obstinate  cases,  and  in  certain  in- 
stances cod-liver  oil  and  the  syrup  of  iodide  of  iron,  are  called  for.     If 


ROSEOLA.  843 

the  derangement  of  the  system  upon  which  the  erythema  depends  appear 
to  be  of  a  rheumatic  character,  colchicum  or  alkalies  may  be  required. 
Erythema  papulatum,  tuberculatum,  and  nodosum  occur  most  frequently 
in  reduced  states  of  the  system,  and  therefore  need  tonics. 


Roseola. 

The  terra  roseola  is  applied  to  rose-colored  spots  or  patches  of  greater 
or  less  extent,  accompanied  by  a  degree  of  febrile  reaction,  and  often 
by  redness,  with  little  or  no  swelling  of  the  faucial  surface.  It  is  at- 
tended bv  a  sensation  of  warmth  and  slin;ht  itching.  The  following 
groups  and  subdivisions  embrace  the  recognized  varieties  of  this  disease: 

EOSEOLA. 

Idiopathic.  Symptomatic. 

Infantilis.  Variolosa. 

JE^tiva.  Vaccinia. 

Autumnalis.  Miliaris. 

Annulata'.  Eheumatiea. 

Punctata.  Arthritica. 

Choleriea. 

Fehris  continuae. 

Syphilitica. 

The  color  of  the  eruption  gradually  fades  from  a  rose-red  to  a  duller 
hue,  and  often  disappears  in  two  or  three  days.  In  other  instances  the 
eruption  lasts  a  week  or  more.  Roseola  may  occur  in  any  season,  but 
it  is  most  common,  especially  the  idiopathic  form,  in  the  warm  months. 
Those  varieties  of  the  idiopathic  disease  which  are  designated  infantilis, 
aestiva,  and  autumnalis  are  the  most  common  in  early  life.  They  are  in 
reality  identical,  or  nearly  so,  and  may  be  described  as  one  disease. 

Symi'TOMS. — Roseola  infantilis,  testiva,  or  autumnalis  maybe  partial, 
appearing  upon  the  arms  and  legs,  or  general.  It  is  often  preceded  by 
febrile  movement,  languor,  and,  in  those  old  enough  to  describe  their 
sensations,  pain  in  head,  back,  and  limbs.  There  is  great  difference, 
however,  in  different  cases  as  regards  the  severity  of  the  prodromic 
symptoms.  They  may  be  absent  or  so  slight  as  scarcely  to  be  appre- 
ciable. Occasionally  vomiting,  diarrhffia,  or  otiier  symptoms  of  derange- 
ment of  the  digestive  ai)i)aratus  immediately  precede  the  erui)tion. 

The  eruption  of  roseola,  when  general,  usually  commences  upon  or 
about  the  neck  and  face,  and  in  the  course  of  twenty-four  to  thirty-si.x 
hours  appears  upon  the  rest  of  the  surface.  It  bears  considerable 
reseml)lance  to  that  of  measles.  The  patches  are  irregidar  in  shape,  a 
quarter  to  half  an  inch  in  diameter,  and,  tliough  of  a  rose  color  at  first, 
they  soon  pi-esent  a  dusky  due  as  they  begin  to  fade;  by  pressure  the 
redness  disappears.  In  tlie  majority  of  cases  the  eruption  has  nearly 
faded  by  the  fifth  day.  The  redness  of  the  faucial  surface,  together 
with  the  itching  or  tingling,  disajipears  with  the  subsidence  of  the  rash. 

Roseola  annulata  is  a  rare  disease.  It  commences  with  constitutional 
symptoms,  which  are  slight  or  ]»retty  severe,  and  which  cease  when 
the  eruption   appears,  this  occurs   in   the  form  of  red  circular  spots, 


84-i  ROSEOLA. 

which  enlarge  to  the  diameter  of  an  inch  or  thereabout  and  assume  the 
shape  of  rings  inclosing  heahhy  skin.  The  rash  fades  in  a  few  days, 
often  leaving  a  bruised  appearance.  The  ordinary  location  of  this  form 
of  erythema  is  upon  the  abdomen,  and  about  the  thighs.  In  roseola 
punctata  the  eruption  is  of  small  size,  and  it  occurs  upon  a  large  part 
of  the  surface. 

Symptomatic  roseola,  which  appears  in  the  coarse  of  various  diseases, 
need  only  be  alluded  to.  The  diseases  in  which  it  is  developed  are, 
with  the  exception  of  syphilis,  chietly  of  an  acute  fsbrile  or  inflamma- 
tory character.  This  eruption  is  often  really,  as  stated  by  Tilbury 
Fox,  a  rose-colored  erythema,  but  in  other  instances  it  presents  the 
typical  form  and  appearance  of  roseola.  Thus  I  have  known  it  to  occur 
about  the  eighth  or  ninth  day  of  vaccinia  in  rose-colored  spots  over  the 
whole  surface,  and  producing  much  anxiety  on  the  part  of  parents,  lest 
impure  virus  had  been  employed. 

Causes, — These  are  in  a  measure  obscure.  The  delicacy  of  the  skin 
in  infancy  and  the  active  cutaneous  circuhition  no  doubt  predispose  to 
reseola  and  erythema,  and  hence  the  frequency  of  their  occurrence  in 
acute  febrile  and  inflammatory  affections.  Summer  weather,  with  the 
derangements  of  system  which  it  produces,  has  been  in  my  experience 
much  the  most  frequent  cause  of  idiopathic  roseola  in  young  children  in 
this  city.  In  certain  summers,  as  in  that  of  1868,  a  large  proportion 
of  the  infants  have  been  affected  by  it,  and  I  have  been  led  to  consider 
it  a  favorable  iiroiinostic  sio;n  as  refirards  the  diarrhueal  affections  which 
are  so  common  in  the  warm  months. 

Prognosis. — Roseola  is  always  a  mild  and  favorable  disease. 

Diagnosis. — Roseola  is  distinguished  from  measles,  by  the  absence 
of  catarrhal  symptoms,  a  less  degree  of  fever,  less  uniformity  in  the  size 
of  the  eruption,  and  the  absence  of  any  history  of  contagion.  Roseola 
is  distinguished  from  erythema  by  the  smaller  size  of  the  eruption  and 
its  rosy  or  dusky  red  color.  The  boundary  line,  however,  between  the 
two  diseases  is  not  well  defined,  and  certain  forms  of  roseola  may  be 
described  as  erythema.  The  general  but  punctiform  efflorescence, 
increase  of  temperature,  acceleration  of  pulse,  and  the  peculiar  appear- 
ance of  the  tongue  and  fauces,  serve  to  distinguish  scarlet  fever  from 
roseola.  There  is  little  danger  of  confoundini?  roseola  with  urticaria, 
since  the  wheals  of  the  latter  appear  in  no  other  disease. 

Treatment. — This  is  simple.  If  roseola  occur  in  connection  with 
gastro-intestinal  derangement  or  disease,  the  remedies  which  relieve  the 
latter  exert  a  curative  effect  upon  the  former.  In  all  cases  the  state  of 
the  system  should  be  inquired  into,  and  any  departure  from  a  state  of 
health  corrected.  Roseola  needs  no  further  constitutional  treatment. 
If  there  be  itching  or  tingling  of  the  surface,  a  lukewarm  lotion,  con- 
taining equal  parts  of  liq.  amnion,  acetat.  and  mistura  campbone,  has 
been  recommended,  or  a  lotion  containing  a  drachm  of  hydrocyanic 
acid  to  a  pint  of  an  emulsion  of  bitter  almonds,  used  warm.  The  pur- 
pose of  sjch  lotions  is  simply  to  relieve  the  unpleasant  sensation.  Gold 
applications,  or  others  which  would  repel  the  eruption,  should  be  avoided; 
such  an  effect  might  be  injurious.  In  case  of  acidity  of  stomach  alkaline 
remedies  are  useful,  and  in  certain  cases  tonic  treatment  is  indicated. 


URTICARIA.  8-i5 


Urticaria. 

The  name  by  which  this  disease  is  designated  is  derived  from  the 
term  urtica,  the  nettle,  the  sting  of  which  produces  this  form  of  erup- 
tion. The  eruption  occurs  suddenly  in  wheals  or  pomphi,  attended  by 
tingling  and  burning,  an<l  suddenly  disappearing.  Urticaria  is  often 
accom])anied  by  no  very  decided  general  symptoms,  but  in  other  cases 
there  are  febrile  movement,  and  lassitude,  with  perhaps  epigastric  pain 
and  headaclie.  The  wheals  may  occur  over  the  whole  body,  but  more 
frequently  are  confined  to  a  portion  of  it.  Their  shape  may  be  round, 
oval,  irregular,  or  band-like,  and  their  length  varies  from  a  few  lines  to 
several  inches.  In  one  affected  by  urticaria  the  wheals  can  be  readily 
produced  by  scratching  or  rul)bing  the  surface.  The  eruption  is  thus 
clearly  described  by  a  recent  writer:  '-At  first  a  bright  Hush  appears, 
the  centre  of  this  becomes  slightly  elevated,  and  pales,  hence  appears 
of  lighter  color ;  the  tint  may  be  rosy,  but  more  generally  it  is  whitish." 
The  margin  of  the  wheal,  the  diameter  of  which  varies,  always  remains 
red.  This  eruption  app.ears  to  be  produced  by  active  congestion  of  the 
cutaneous  capillaries,  some  serous  effusion,  and  spasm  of  the  muscular 
fibres  of  the  skin.  The  effusion  of  serum  in  certain  localities  is  quite 
apparent  from  the  oedema  which  occurs.  The  subsidence  of  the  erup- 
tion is  without  desquamation.  Urticaria  is  ordinarily  an  acute  disease. 
It  is  sometimes  chronic  in  the  adult,  but  rarely  so  in  children.  Several 
varieties  of  it  are  described  by  dermatologists,  according  to  the  cause, 
appearance,  and  duration. 

Causes. — These  are  external  and  internal.  Various  irritants  apart 
from  the  nettle  applied  to  the  surface  produce  the  wheals,  as  the  bites  of 
certain  insects  and  sometimes  turpentine.  The  following  are  the  prin- 
cipal internal  causes,  as  summarized  by  Hillier:  1st,  profound  and 
sudden  mental  emotion  ;  2d,  certain  articles  of  diet,  as  shell-fish,  pork, 
sausage,  cheese,  etc.;  3d,  certain  medicinal  substances,  as  copaiba,  vale- 
rian, and  turpentine;  4th,  intestinal  worms,  though  it  is  probable  that 
these  seldom  operate  as  a  cause  ;  5th,  uterine  ailments,  as  hysteria. 

Prognosis — Diagnosis. — The  prognosis  is  good,  though  the  chronic 
form  is  sometimes  tedious  and  troublesome.  The  occurrence  of  the 
wheals  and  the  possibility  of  producing  them  by  friction  serve  to  dis- 
tinguish this  disease  from  all  others. 

Treats KNT. — In  urticaria  due  to  recent  ingcsta  of  an  irritating 
or  indigestible  character,  an  emetic  of  ipecacuanha  is  useful,  followed 
by  a  saline,  and  better  also  alkaline  aperient,  as  Rochelle  salts.  An 
aperient  of  this  kind  is  useful  ordinarily  in  acute  cases,  attended 
by  febrile  reaction.  The  diet  for  several  days  should  be  simi)le,  and 
such  as  is  readily  digested,  as  fresh  beef,  bread,  or  other  farinaceous  food, 
and  milk.  Occasionally  the  wheals  appear  periodically,  when  a  few  doses 
of  quinine  effect  a  prompt  cure.  After  the  above  measures  have  been 
employed,  the  8ul)se(iuent  treatment,  whether  tonic  or  otherwise,  de- 
pends on  the  condition  of  the  ])atirnt.  Little  benefit  accrues  from  local 
measures.  Sponging  the  surface  with  cool  water  to  which  a  little  vinegar 
is  added  relieves,  in  a  measure,  the  heat  and  tingling  of  the  wheals. 


84:Q  PAPULAR    DISEASES. 


CHAPTER   IT. 

PAPULAE  DISEASES. 
Strophulus. 

The  three  papulae,  namely,  lichen,  prurigo,  and  strophulus,  which 
are  characterized  by  small  and  firm  elevations  upon  the  skin,  occur  in 
children  ;  but  the  two  former  are  not  common,  and,  as  they  do  not 
differ  in  any  essential  particular  from  the  same  diseases  in  the  adult, 
they  will  not  be  treated  of  in  this  connection.  Strophulus,  on  the  other 
hand,  is  a  disease  peculiar  to  children.  It  is  known  as  the  red  gum  or 
white  gum,  according  to  its  appearance,  and  also  as  the  tooth  rash. 
This  eruption  appears  usually  on  parts  which  are  exposed,  as  the  face, 
neck,  and  extremities,  the  papules  being  in  so.ne  patients  of  the  size  of, 
or  even  smaller  than,  a  ^jin's  head,  while  in  other  cases  they  are  as  large 
as  a  millet-seed. 

The  varieties  of  strophulus  described  by  dermatologists  are : 

S.  intertinctus.  S.  candidus. 

"    cnnfertus.  "    volaticus. 

"    albidus.  "    pruriginosus. 

The  following  are  the  characters  of  these  varieties  :  S.  intertinctus, 
papules  bright  red,  and  occurring  chiefly  upon  the  cheeks,  forearm,  and 
back  of  hand ;  often  intertinctured  Avith  blushes  of  erythema ;  it  lasts 
from  two  to  four  weeks,  and  is  most  common  in  young  infimts.  S.  con- 
fertus,  papules  numerous,  and  closely  aggregated,  paler,  continuing 
longer  than  in  strophulus  intertinctus,  and  likely  to  recur,  appearing 
about  the  time  of  dentition,  and  most  frequently  upon  the  arm.  Some- 
times certain  of  the  patches  become  chronic,  slowly  disappearing,  and 
leaving  the  skin  rough  and  dry.  S.  volaticus  appears  usually  upon  the 
arms  and  cheeks  in  patches  of  about  a  dozen,  fewer  or  more,  papules, 
which  soon  disappear.  These  patches  reappear  at  intervals  for  two  or 
three  weeks,  and  are  attended  by  heat  and  itching,  though  not  intense. 
S.  albidus,  so  called,  should  really  be  placed  among  the  diseases  of  the 
sebaceous  glands,  and  described  under  another  name.  It  appears  in  the 
form  of  small  white  elevations  as  large  as  a  pin's  head,  commonly  upon 
the  face  and  neck,  and  produced  by  distention  of  the  sebaceous  glands 
with  the  secreted  product.  The  term  strophulus  candidus  is  applied  to 
large  whitish  papules,  which  appear  upon  the  sides  of  the  trunk,  shoul- 
ders, and  arms  of  infants  of  one  year  or  thereabouts,  and  disappear  in 
about  one  week.  They  are  liable  to  be  associated  Avith  tlie  papules  of 
strophulus  confertus.  S.  pruriginosus  is  really  a  form  of  lichen,  occur- 
rincr  chiefly  above  the  age  of  one,  and  under  that  of  eight  or  nine  years. 
The  papules,  which  are  small  and  discrete,  usually  appear  over  a  large 


ECZEMA.  847 

extent  of  snrf^ice,  ordinarily  upon  the  back,  front  of  the  chest,  the  face 
and  arms,  and,  as  they  are  scratched  from  the  itching,  minute  dark 
points  of  blood  collect  and  dry  upon  their  apices.  This  form  of  stro- 
phulus is  more  protracted  than  the  others,  and,  in  consequence  of  the 
irritation  produced  by  the  scratching,  pustules  of  ecthyma  often  occur 
among  the  papules.  The  apparent  cause  of  stropliulus  pruriginosus  is 
a  mode  of  life  which  impoverishes  and  vitiates  the  blood,  such  as  un- 
cleanliness,  and  residence  in  damp,  dark,  overheated,  and  overcrowded 
apartments.  Atmospheric  heat  also  operates  as  a  cause  of  this  form  of 
strophulus,  and  it  is  not  an  infrequent  disease  in  cities  during  summer 
months. 

The  various  eruptions  included  under  the  term  strophulus  have  such 
different  anatomical  characters,  that  a  proper  classification  would  locate 
some  of  them  in  other  groups  of  skin  diseases.  One  form  of  it,  as  we 
have  seen,  is  producerl  by  distention  of  the  sebaceous  glands;  in  other, 
and  the  majority  of  cases,  as  appears  from  the  recent  observations  of 
Mr.  Fox,  its  seat  is  the  sweat  glands,  and  in  others  still  the  papillary 
layer  of  the  skin,  as  in  lichen,  the  papules  being  produced  by  an  exu- 
dation. 

Treatment. — Personal  cleanliness,  with  frequent  change  of  linen, 
and  daily  ablution  without  the  use  of  soap,  should  be  enjoined.  Local 
irritants,  which  might  aggravate  or  cause  the  disease,  should,  so  far  as 
practicable,  be  removed.  Alkalies  in  cases  of  acidity  of  the  primce  vice., 
and  occasionally  mild  aperients,  are  required",  the  food  should  be  bland, 
but  nutritious,  and  if  tlie  child  be  nursing,  it  may  be  necessary  to  attend 
to  the  healh  of  the  wet-nurse.  Favorable  hygienic  conditions,  impor- 
tant for  the  successful  treatment  of  all  forms  of  strophulus,  are  especially 
required  in  strophulus  pruriginosus.  Nutritious  diet,  fresh  air,  quinine, 
iron,  cod-liver  oil,  etc.,  should  be  prescribed  for  those  affected  by  it. 
The  following  formula  is  recommended  for  sponging  the  surface  in  cases 
of  strophulus: 

li. — Soflii  carbonat 9J. 

Glyoerinae       .         .         .         .         .         .         .         •      3'J- 

Aq.  rosaB 5vj. — Misce 


CHAPTER   III. 

ECZEMA. 


This  is  one  of  the  most  common  maladies  of  the  skin.  It  constituted 
one-third  of  Devergie's  cases,  and  one-sixth  of  Ilillier's.  In  the  com- 
mencement of  the  eczematous  eruption  the  skin  jtresents  a  superficial 
redness,  and  upon  this  inflamed  area  numerous  minute  and  closely  ag- 
gregated papules,  vesicles,  or,  more  rarely,  pustules,  a|)poar.  These 
are  very  fragile,  so  that  they  soon  rupture,  the  epidermis  is  broken  and 


848  ECZEMA. 

destroyed,  and  the  surface  is  moistened  by  an  effusion  which  appears  to 
be  serum,  and  cannot  l)e  distinguished  from  it  by  the  microscoj)e.  This 
liquid  ■when  dry  stiffens  linen.  As  it  dries  thin  crusts  form,  of  a  light 
yellow  color  upon  most  parts  of  the  surface,  but  they  are  thicker,  and  of 
a  deeper  yellow  color,  upon  the  scalp  than  elsewhere.  The  crusts  consist 
mainly  of  pus,  epithelial  cells,  and  granular  matter. 

Anatomy. — Biesiadecki  has  described  the  formation  of  the  eczematous 
eruption.  According  to  him,  the  papules  are  produced  from  the  papilhe, 
which  increase  in  size  by  cell  formation  in  their  interior.  The  connec- 
tive-tissue corpuscles  enlarge,  and  are  unusually  "rich  in  fluid,"  and 
their  number  inci'eases.  Under  the  microscope  spindle-shaped  corpus- 
cles are  observed,  filling  the  papillae,  and  extending  up  from  them  into 
the  rete  Malpighii,  crowding  apart  the  cells  of  this  layer,  and  reaching 
and  elevating  the  epidermis.  The  epithelial  cells  in  the  immediate 
vicinity  of  the  papillre  also  become  swollen.  This  cell-growth  produces 
the  eczematous  papule. 

If  the  cell  formation  continues  within  a  papilla,  certain  of  the  cells 
are  ruptured,  and  as  they  are  very  moist  a  liquid  is  effused,  which  raises 
the  epidermis  over  the  summit  of  the  papilla.  This  produces  the  ecze- 
matous vesicle.  Occasionally  pus  mixes  with  this  liquid,  and  the  erup- 
tion is  then  vesico-pustular. 

In  acute  eczema  the  upper  part  of  the  true  skin  is  infiltrated  and 
swollen,  Avhile  the  lower  part  is  commonly  unaffected,  except  in  the 
most  severe  cases.  The  older  the  eczema  the  greater  the  extent  of  the 
infiltration,  so  that  in  chronic  eczema  the  whole  thickness  of  the  skin  is 
more  likely  to  be  involved  than  in  acute  forms  of  the  malady.  The  dis- 
charge of  the  eczematous  surface  is  irritating,  and  healthy  skin,  with 
which  it  may  come  in  contact,  is  often  reddened  by  it  and  made  eczema- 
tous, from  its  irritating  effect.  This  eczema  occurring  upon  a  part  of 
the  surface  which  is  in  contact  with  an  opposite  surface  of  sound  skin, 
commonly  affects  the  latter,  and,  as  Neumann  has  stated,  a  nurse,  by 
carrvino-  an  infant  having  eczema  upon  its  nates,  may  contract  the 
same  disease  upon  her  arm,  although  there  is  no  contagious  principle  in 
this  malady. 

Etiology. — Eczema  is  often  produced  by  irritating  substances  applied 
to  the  skin.  Croton  oil,  certain  soaps,  the  finger-nails  in  scratching,  a 
hat,  truss,  or  belt,  by  pressure  may  produce  it.  Those  having  a  tender 
and  delicate  skin  are  more  liable  to  it  than  others.  The  constitutional 
causes  are  often  obscure.  It  is  sometimes  obviously  due  to  indigestion, 
or  a  diet  which  disagrees,  for  we  see  it  occur  in  nursing  infimts  as  a 
result  of  sickness  of  the  mother.  Anaemia  and  scrofula  are  occasional 
causes.  Among  the  city  poor  eczema  is  common,  and  many  of  the 
children  Avho  have  it  are  scrofulous,  but  a  large  proportion  show  no 
evidence  of  struma,  and  in  the  better  classes  of  society  a  majority  do 
not. 

Yakieties — Symptoms — Course. — Eczema  is  sometimes  designated 
according  to  its  location  as  E faciei,  capitis,  etc.  Another  designation, 
which  has  more  scientific  value,  is  according  to  the  form  and  stage  of 
the  eruption,  by  which  we  have  the  following  recognized  varieties,  to 
wit:    Eczema  papulosum,  vesiculosum,  pustulosum,  rubrum,  impetigi- 


VARIETIES — SYMPTOMS — COURSE.  8-±9 

nosum,  and  squamosum.     A  simpler  and  still  more  convenient  classifi- 
cation is  into  eczema  simplex,  rubrum,  impetiginosum,  and  squamosum. 

Eczma  of  the  scalp  is  common  in  infancy,  occurring  as  an  eczema 
rubrum  or  impetiiiinosum.  The  eczematous  exudation  mino-linfr  with 
the  secretion  ot  the  sebaceous  glands,  which  are  numerous  upon  the 
seal;),  forms  a  thick  yellow  crust.  It  is  likely  to  extend  beyond  the  hairy 
portion  to  the  forehead  and  around  the  ears.  This  extension  aids  in 
establishing  the  diagnosis  between  eczema  and  certain  other  cutaneous 
eruptions  of  the  scalp.  Eczema  of  the  external  ear  is  sometimes  )»rimary, 
but  in  other  instances  it  is  consecutive  to  that  of  the  scalp,  and  due  to 
extension  of  the  latter.  Its  common  seat  is  in  the  angle  behind  the 
ear,  and  upon  the  lobe  of  the  ear,  wdience  it  often  extends  along  the 
auditory  meatus,  narrowing  its  calibre,  and  impairing  the  hearing  tem- 
porarily, or  even  for  years.  "  Eczema  upon  the  forehead  commonly 
occurs  in  children  from  extensif)n  of  thn  eruption  from  the  scalp.  The 
cheeks,  lips,  and  chin  are  often  also  aiTected  by  eczema,  whicii  in  this 
situation  is  commonly  eczema  rubium,  and  is  attended  by  redness,  swell- 
ing, and  troublesome  itching.  The  swollen  and  red  appearance  with 
the  crusts  and  marks  produced  by  scratching  often  greatly  disfigure  the 
countenance.  In  children,  when  eczema  occurs  upon  other  parts,  it  is 
usu:dly  associated  with  that  of  the  scalp,  face,  or  ears — that  in  the  latter 
situations  being  the  most  severe  and  obstinate. 

Eczema  simplex  is  common  in  the  summer  months,  being  produced  by 
the  heat  of  the  atmosphere,  aided  perhaps  by  other  causes.  The  patient 
may  appear  well,  or  be  somewhat  indisposed,  having  febrile  symptoms, 
and  soon  an  erythematous  patch  of  greater  or  less  extent  appears,  upon 
whicli  a  cluster  of  the  characteristic  [lapules  or  vesicles  soon  occurs. 
These  break,  forming  slight  crusts,  which  are  detached,  and  the  eczema 
declines,  or  it  may  continue  longer,  with  successive  crops  of  the  eruption. 

In  eczema  riihrum,  since  it  is  a  more  severe  form  of  the  disease,  the 
febrile  movement  and  the  local  symptoms  are  greater  than  in  the  preced- 
ing variety,  and  the  eczematous  jiatch  presents  the  appearance  of  a  more 
intense  infiammation.  The  ]»apules  or  vesicles  are  often  so  miimte  as 
to  be  with  dilHcidty  recognized.  They  are  soon  broken,  when  they 
form  with  the  secretion  and  exudation  from  the  surface  yellowish  or 
brownish-yellow  scabs.  The  discharge  is  more  irritating,  as  it  is  more 
abundant  than  in  eczema  simf)lex.  and  the  adjacent  skin  is  usually  more 
inllamed  from  its  contact. 

Ecz''ma  impi'tijiinodi's  is  common  in  young  dc))ilitated  chihlren,  in 
who.n,  in  consequence  of  the  cachexia,  inliainmations.  <if  whatever  char- 
acter, are  liable  to  be  suppurative.  This  f(»rm  of  eczema  presents  at  first 
the  symptoms  and  features  of  eczema  rubruTii,  but  the  transparent  licjuid 
of  the  vesicles  soon  becomes  opa(|ue,  from  the  generation  and  admixture 
of  ])US-corpuscles.  The  crusts,  which  fi)nn  from  the  riij»ture  and  desic- 
cation of  the  vcsiculo-pustular  eruption^,  are  thick  and  greenish-yellow, 
and  in  infants  the  sel>aceous  glands,  which  ar<'  involved  in  the  inllam- 
mation,  ])our  out  an  abundant  secretion,  increasing  the  thickness  of  the 
crusts.  This  form  of  eczema  is  most  common  in  infancy,  and  its  usual 
scat  is  upon  the  scalj>. 

54 


850  ECZEMA. 

Diagnosis. — Eczema  presents  in  different  instances  so  different  an 
appearance  that  it  is  not  always  readily  diagnosticated.  It  will  aid  in 
its  diagnosis  to  recollect  that  it  is  in  its  nature  a  catarrh,  affecting  prima- 
rily and  chiefly  the  upper  portion  of  the  derma  and  tlie  Malpighian 
layer,  and  although  it  may  now  present  a  dry  or  scaly  aj)pearancc 
(E.  squamosum),  yet  its  history  will  show  that  there  has  been  a  discharge 
or  moisture.  In  a  large  proportion  of  cases,  the  physician  is  not  able  to 
detect  papules  or  vesicles,  since  they  are  fragile  and  transient,  breaking 
in  the  first  thirty-six  hours,  and  not  reappearing.  Still,  when  they  are 
absent,  we  sometimes  observe  around  the  margin  of  the  patch  an  appear- 
ance which  indicates  that  they  have  been  there.  Their  minuteness  is 
occasionally  such  that  they  may  escape  notice,  on  a  cursory  inspection, 
when  they  are  present  and  well  defined.  Acute  eczema,  affecting  a  con- 
siderable extent  of  surface,  is  often  attended  by  febrile  movement,  and 
may  be  mistaken  for  one  of  the  eruptive  fevers,  but  the  absence  of  cer- 
tain distinctive  appearances  which  characterize  these  fevers,  and  the 
speedy  appearance  of  the  eruption  and  moisture,  establish  the  diagnosis. 
Eczema  can  be  readily  diagnosticated  from  ordinary  erythema,  which  is 
a  superficial  inflammation  without  moisture.  The  location  of  erythema 
intertrigo  serves  for  its  diagnosis,  as  it  is  evidently  produced  by  the 
attrition  of  opposite  surfaces  of  the  skin.  Moreover,  it  lacks  the  ele- 
vated papillae,  and  the  discharge  does  not  stiffen  linen  like  that  of 
eczema.  Lichen,  when  acute,  presents  some  resemblance  to  eczema,  but 
it  is  dry  and  papular,  the  papules,  though  small,  being  detected  by  the 
finger  as  well  as  sight.  The  lai'ge  and  irregular  phlyctenule,  intense 
inflammation  and  oedema,  and  mode  of  extension  of  erysipelas ;  large, 
scattered,  and  non-inflammatory  vesicles  of  sudamina;  scattered  and 
acuminate  vesicles,  without  surrounding  inflammation,  of  scabies;  are 
so  different  from  the  eczematous  eruption  that  the  difi'erential  diagnosis 
from  those  diseases  is  readily  made.  Herpes  circinatus  can  be  distin- 
guished from  eczema  by  its  circular  shape,  larger  size,  and  greater  per- 
manence of  the  vesicles,  and  the  delicate,  branny  scales,  which  consist 
rather  of  epithelial  cells  than  the  product  of  exudation  as  in  eczema. 

Treatment. — Eczema  should  be  cured  as  speedily  as  possible,  since 
there  is  no  danger  that  another  disease  will  arise  from  the  disappearance 
of  the  eruption,  Avliile,  on  the  other  hand,  the  restlessness  and  fretfulness, 
which  the  eruption  often  produces,  may  impair  the  general  health,  and 
the  lymphatic  glands  receiving  lymph  from  the  eczematous  patches  may 
undergo  hyperplasia  and  cheesy  degeneration.  Many  cases  can  be 
cured  by  strictly  local  measures,  while  in  others,  as  when  there  is  a 
markedly  strumous  cachexia  or  other  manifest  aberration  from  the 
healthy  standard,  constitutional  measures  are  important. 

Constitutional  Treatment. — No  one  line  of  treatment  is  suitable  for 
every  patient.  Among  the  city  poor  strumous  cases  are  common,  and 
cases  also  in  which,  Avithout  any  pronounced  diathetic  state,  the  cause  is 
apparently  a  reduced  state  of  the  system  from  innutritious  diet  and  other 
antihygienic  conditions.  Such  cases  require  better  diet,  and  a  mode  of 
life  more  in  accordance  with  sanitary  requirements.  On  the  other 
hand,  I  have  observed  cases  of  eczema  which  seemed  to  be  produced  or 
rendered  more  intractable  by  a  plethoric  rtate  of  the  system,  especially 


TEEATMENT.  851 

in  the  nursing  infant,  when  the  milk  of  the  mother  or  wetnurse  was 
unusually  rich  or  abundant.  AVhile,  therefore,  ill-nourished  and 
weakly  children  require  better  regimen,  with  perhaps  vegetable  and 
ferruginous  tonics,  the  plethoric  require  reducing  treatment,  though  of 
a  gentle  kind.  Their  food  should  be  plain  and  unstimulating.  Indi- 
gestible articles,  as  pastries,  cheese,  and  rich  sauces,  should  be  avoided, 
especially  when  symptoms  of  indigestion  are  present.  Indigestion  or 
other  aberration  of  the  system  from  the  healthy  standard,  should  be 
promptly  corrected.  Saline  aperients  are  useful  in  cases  of  constipation 
and  of  a  plethoric  habit.  The  saline  diuretics,  as  the  acetate  and  citrate 
of  potassium,  are  often  beneficial  in  acute  eczema  with  febrile  symptoms, 
especially  if  the  urine  be  rather  scanty.  The  following  formula  is  re- 
commended by  Dr.  A.  R.  Robinson : 

R. — Potassi  acetatis .^i^s. 

Spi^.  ictheri?  nitrosi       .         .         .         .         .         .      ^ij. 

Syrnpi  aiirantii      .         .         .         .         .         .         •      3^'j- 

Aqu:e  carui   ........     q.s    afl.    5iij. 

One  teaspooiiful  three  times  daily  to  a  ctiiid  of  one  year. 

In  acute  as  well  as  chronic  eczema  any  departure  from  the  healthy 
standard,  whether  in  the  digestive  organs,  the  kidneys,  or  other  part  of 
the  .system,  should  be  corrected  so  far  as  possible,  since  eczema  is  more 
readily  cured  when  the  functions  of  the  internal  organs  are  normally 
performed. 

Chronic  eczema  as  well  as  acute  often  requires  internal  remedies, 
although  they  are  of  less  importance  than  external  measures.  In 
anaemic  cases,  iron  is  indicated,  and  arsenic,  which  should  not  be  used 
in  acute  and  moist  eczemas,  often  produces  a  very  beneficial  effect,  espe- 
cially in  dry  eczemas,  when  accompanied  by  much  infiltration.  In 
many  cases  of  chronic  eczema  the  following  prescription  will  be  found 
useful  : 


R. — Liq.  potR'sae  arsenit f.^j. 

Tiiic.  ferri  pDniati.   "j  --  .„ 

Ti    •     ■    •  >■  .         .         .         .         .         .     aa  t  :?  V. 

inc.  rhei  vini  J  ^ 

Aq.  menih.  ........     f^'^'- — Misce. 

Dose,  one  leaspoonful  three  times  daily  to  a  child  of  one  to  two  yoar.s. 

External  Treatment.  Acute  Eczema. — Thee.xternal  treatment  should 
be  difTerent  in  different  cases,  according  to  tiie  stage  of  the  disease  and 
the  condition  of  the  affected  surface.  In  acute  eczema,  irritating  and 
stimulating  a[)plications  are  inadmissible.  Even  the  garments  worn 
should  be  as  little  irritating  as  possible  upon  parts  covered  by  the  dress. 
It  is  even  recommended  that  the  patient  lie  in  bed  in  .severe  general 
eczema,  with  a  light  covering  of  l>edcIothes.  Water  is  usually  too 
irritating  for  eczema,  so  that  baths  and  washes  should  be  interdicted. 
Ordinary  soap  should  never  be  employed  in  the  acute  disease,  as  it  is  too 
irritating.  When  the  use  of  water  is  necessary  for  ))iirposes  of  cleanli- 
ness, bran  water,  or  thin  flax.seed  tea,  or  other  mucilaginous  infu.sion 
shouM  be  used.  In  eczema  infertn'ijn,  so  common  upon  the  groin  and 
nat<'S  of  infants,  cotton  batting,  or  the  al»sorbent  cotton  of  the  shops, 
dusted  with  the  following  finely  triturated  powder,  should  be  constantly 


852  ECZEMA. 

applied,  so  as  to  come  tlioronglily  in  contact  with  the  inflamed  surfaces 
and  separate  them:  boracic  acid  one  ])art,  salicyhc  acid  one  part,  sub- 
nitrate  of  bismuth  or  oxide  of  zinc  five  ]);irts. 

Pruritus. — Itching  is  a  fre(|uent  and  annoying  symptom  of  eczema, 
and  whatever  curative  applications  may  be  made  use  of,  somethin<T  to 
relieve  this  symptom  is  often  rerpiired.  Camphor  mixed  with  ointments 
or  washes,  relieves  itching.  A  two  per  cent,  solution  of  acetic  acid, 
or  a  half  to  a  tAvo  per  cent,  solution  of  aluminium  acetate  in  water, 
also  frecpiently  gives  relief.  Carbolic  acid  is  one  of  the  most  efllectual 
agents  to  relieve  pruritus.  The  following  formula  is  essentially  that 
recommended  by  Kaposi : 

JJ. — Acidi  carbolici <rrMmmes  xv. 

Spts.  vini  giillici    .  .....  fzv. 

Tine,  luvendul. ")  .     .       . 

Ehu  de  cologne/ ''"'3^'J- 

Glycerini ^j. — ;\Iisce. 

Veiel  says  that  even  this  small  amount  of  glycerine  is  sometimes  too 
stimulating  to  the  surface,  and,  if  so,  it  should  be  omitted. 

Curative  Applications. — In  the  commencement  of  eczema  papulosum 
or  vesiculosum,  common  powdered  starch,  talc  (magnesium  silicate), 
semen  lycopodii,  or  rice  starch  (amylum  oryzas),  is  beneficial  for  dusting 
the  part.  The  following  formula  is  substantially  that  recommended  by 
Kaposi  : 

K- — Amyli  orizse .      ^iij. 

Talc  venet.  "| 

Flor.  zinci,  V a^^  SJ  X- 

Pulv.  irid.  floreni.  J 

Mi  see. 

Camphor  may  be  added  to  this  to  relieve  itching,  in  the  proportion 
of  two  per  cent. 

Curative  Applications. — For  healing  tlio  eczema  iu  its  acute  stage, 
the  followinjr  ointments  are  the  most  useful: 


R. 


Va'elinc',  | Equal  part.. 


Ung.  zinci  benzoat,  either  in  full  strength  or  reduced  by  mixture  with 
vaseline.  In  full  strength  it  is  sometimes  too  irritating.  Crusts  should 
be  removed  by  soaking  them  with  oil,  or  by  an  emollient  poultice,  and 
some  hours  subsequently  Avashing  the  surface  Avith  Avarm  Avater.  If  the 
surface  be  moist,  tlie  poAvder,  prepared  according  to  the  above  formula, 
can  often  be  advantageously  used  instead  of  the  ointment.  A  convenient 
and  effectual  Avay  of  using  the  ointment  is  to  spread  it  thickly  on  linen 
or  lint,  Avhich  is  then  bound  doAvn  by  gauze.  In  eczema  facei,  a  mask 
may  be  made  Avith  openings  for  the  nose,  eyes,  mouth,  and  ears,  and 
bound  down  upon  the  surface.  In  that  form  of  eczema  in  which  the 
skin  is  red  and  desquamating,  the  milder  ointments  should  be  used, 
rubbed  in  three  times  daily. 

Chronic  Eczema. — The  crusts  should  bo  remoA'ed  by  strips  of  linen 
or  gauze  soaked  Avith  cold  distilled  Avater,  and  frequently  applied,  so  that 
the  Avater  does  not  become  warm,  for  Avarm  Avater  applications  by  their 
irritating  action  may  produce  eczema.      An  C(pial  quantity  of  Goulard's 


ECZEMA.  853 

extract  may  be  added  to  the  water  if  the  skin  is  irritable  (Yeiel). 
Oils  are,  however,  in  most  instances,  preferable  to  water  for  the  removal 
of  crusts.  Cod-liver  oil,  mutton  suet,  or  one  of  the  mild  ointments,  as 
cold  cream,  should  be  thoroughly  applied  by  a  painter's  stiff'  brush  upon 
parts  covered  by  hair,  so  as  to  break  through  the  crusts.  On  smooth 
surfaces,  an  ointment,  as  simple  cerate,  should  be  thickly  spread  on 
surgeon's  lint  or  flannel,  and  applied  over  the  crusts,  which  will  usually 
come  away  on  the  removal  of  the  plaster.  A  mild  soap,  the  alkali  of 
which  dissolves  the  epidermis,  will  remove  those  crusts  which  the  above 
measures  fail  to  clean  off",  as  Sargs  liquid  glycerine  soap.  Lately 
salicylic  acid  has  come  into  use  as  a  solvent  of  crusts.  The  following 
ointment  rubbed  in  hourly,  or  applied  thickly  spread  on  surgeon's  lint, 
in  a  few  days  renders  the  surface  clean  : 

R. — Acidi  s^alicvlic.        .         .         .         .         .         .         .      si.       , 

V  a-eline  ........      51SS. — Misce. 

The  first  indication  has  now  been  accomplished,  that  of  denuding  the 
surface  of  crusts.  The  next  indication  is  to  cure  the  disease.  In 
order  to  heal  the  moist  surface  the  best  application  in  most  cases  is  still 
the  diachylon  ointment,  -the  emplastrum  plumbi  recommended  above,  or 
the  zinc  ointment,  by  which  the  moist  eczema  becomes  squamous.  If 
the  surface  is  slow  in  healing,  iSarg's  liquid  glycerine  soap  or  the  fol- 
lowing : 

K  . — Sapnnis  viridis       .......     200. 

Spirit,  rectific.         .....'..     100. 

Digeslre  filtre; 

should  be  poured  upon  moist  flannel  rubbed  in,  and  then  removed  with 
tepid  water.  After  drying  the  parts  the  ointment  should  be  reapplied. 
Occasionally,  on  parts  to  which  the  lead  or  zinc  ointment  cannot  be 
conveniently  applied,  as  upon  the  fjice,  one  part  of  tannin  to  ten  or 
fifteen  of  vaseline  or  cold  cream  may  be  used  instead. 

By  the  above  treatment  the  moist  surface  usually  becomes  Sfjuamous. 
The  eczematous  patch  is  still  hypernemic,  infiltrated,  and  dcsc^uamating, 
and  additional  measures  are  required  to  restore  it  to  the  normal  state. 
Moderately  stimulating  applications  are  now  required,  and  tar  is  the 
best  agent  for  this  purpose.  Tar  should  never  be  applied  in  moist 
eczema.  Its  use  should  be  reserved  for  the  dry  and  desquamating 
eczema. 

The  various  tars,  which  have  been  used  with  success  in  eczema,  are 
the  pix  liquida  or  pine-tar,  the  oleum  fugi  or  beech-tar,  the  oleum  rusci 
or  birch-tar,  and  the  oleum  cadinum  obtained  from  the  jiini|)eri8  oxy- 
cedrus.  Tar  penetrates  all  the  layers  of  the  skin,  for  when  used  exter- 
nally it  lias  been  found  in  tlie  urine.  In  a  few  patients  it  is  stated  lliat  its 
employment  has  been  followed  by  rigors,  fever,  headache,  and  vomiting. 
If  such  symptoms  ari.se,  its  use  should  of  course  be  discontinue*!.  The 
following  formuhe  may  be  employed : 

R. — Ung.  pifis  liquidiB ^j. 

AlJi)hoiis 51J.  —  Misce. 

R. — Oici  rusci  vel.  cadini      .  .         .         .         •     *^5!- 

Alcoholis f5ij-iij. — Misce. 

Uhc  i-xtcrnKlly. 


854 


SCABIES, 


R. — Olei  riipci  vel.  cadini 
Alcoliolis     "I 
Eiberis         / 


aa  f  5iss. — Misce. 


Use  externally. 


Tar  is  useful  when  the  skin  chaps,  or  is  rough.  In  cases  that  are  in  a 
state  of  transition  from  the  acute  and  moist  to  the  chronic  and  squamous 
form  of  the  disease,  the  mixture  of  the  tar  ointment  Avith  the  diachylon 
ointment  often  has  a  salutary  effect. 


Scabies. 

The  diseases  of  the  skin  previously  considered  are  non-contagious. 
Scabies,  on  the  other  hand,  is  one  of  the  most  contagious  diseases  by 
contact.  It  is  produced  by  an  animal  parasite,  known  as  the  itch-mite, 
or  acarus  scabiei.  The  inflammation  is  caused  by  the  female  only, 
which  burroAvs,  making  for  itself  a  canal,  or  cuniculus,  in  Avhich  its  eggs 
are  deposited.  The  male  does  not  burrow,  but  conceals  itself  under  the 
scales  or  crusts  which  result  from  the  inflammation  produced  by  its 
partner,  or  it  burrows  only  sufficiently  to  produce  a  covering  and  shelter. 
From  observations  made  by  Eichstedt,  Gudden,  and  others,  the  female 
has  been  found  within  half  an  hour  after  being  placed  upon  the  skin  to 


Fig.  37. 


Fig.  38. 


Fig.  39. 


mm' 


Fig.  40. 


0 
0 


Fio.  37.  The  itch  animalcule,  acarus  scabiei,  viewed  upon  the  back,  Bhowing  its  figure  and  the  arrange- 
ment of  its  spines  and  filaments.  The  female,  which  is  somewhat  larger  than  the  male,  has  a  length 
of  l-80th  to  1-GOth  of  an  inch. 

Fig.  38.     Tlie  foot  and  last  joints  of  tlio  leu  of  the  itch  animalcule 

Fig.  39  The  male  itch  animalcule,  viewed  upon  the  under  surface,  showing  its  legs  and  lobulated 
feet. 

Fig.  40.     Ova  of  the  itch  animalcule. 

have  concealed  herself  in  the  epidermis,  and  the  burrow  which  she  con- 
structs is  arched  and  tortuous,  and  four  or  five  lines  in  length,  shorter 
or  longer.  The  acarus  has  the  shape  of  a  tortoise.  It  can,  when  fully 
grown,  be  detected  by  the  eye  as  a  minute  whitish  point.  The  young 
acarus  has  six,  the  mature  eight,  articulated  legs,  with  suckers  upon  the 
two  anterior  pairs,  and  hairs  on  the  posterior.  The  head,  whicli  can  be 
elongated  or  retracted,  is  provided  with  two  jaws.     The  upper  surface 


TREATMEXT.  855 

IS  covered  Tvitli  spines  directed  backward  so  as  to  prevent  retrogression 
in  the  burrow.  She  leaves  behind  her  in  the  cuniculus.  as  siie  advances, 
her  moulted  skin,  excreta,  and  eggs,  which  hatch  on  the  eleventh  day. 
The  mother  acarus  is  always  found  at  the  remote  end  of  the  burrow, 
where  it  can  be  seen  by  the  unassisted  eye  as  a  minute  whitish  or  some- 
times brownish  speck,  and  from  which  it  can  be  lifted  by  the  point  of  a 
needle,  to  which  it  clings.  The  cuniculi  can  also  be  seen  by  the  naked 
eye,  looking,  says  ISTiemeyer,  like  the  "  scars  of  needle  scratches,"  and 
containing  the  young  acari  in  various  stages  of  growth. 

The  acarus  by  its  burrowing  produces  an  irritation  and  troublesome 
itching,  Avhich  is  the  chief  cause  of  the  suffering  of  the  patient.  At  the 
point  where  the  acarus  penetrates  the  cuticle  the  inflammation  gives  rise 
to  a  single,  small,  and  acuminate  vesicular  or  papular  eruption,  the 
cuniculus  extending  away  from  it.  "We  often  find  ecthymatous  pustules 
and  abrasions  intermingled  with  the  vesicles,  the  result  of  frequent 
scratching.  The  itching  is  most  intense,  and  the  acarus  most  active, 
at  night,  when  the  patient  is  warm  in  bed.  Scabies  most  frequently 
appears,  especially  in  adults,  first  upon  the  hands,  between  the  fingers, 
where  the  skin  is  thin,'  and  it  extends  thence  along  the  forearm,  and 
over  the  thighs  and  abdomen.  In  children  it  not  infrequently  occurs 
upon  the  buttocks,  thighs,  feet,  etc.,  while  the  hands  and  forearm 
escape. 

Diagnosis, — Correct  diagnosis  is  importajit,  because  the  treatment  re- 
quired is  different  from  that  in  any  other  exanthem,  and  because  the 
suspicion  of  having  this  disease  always  renders  one  solicitous  to  know 
the  exact  nature  of  the  eruption.  Scabies  can  be  diagnosticated  from 
those  diseases  for  which  it  may  be  mistaken  by  the  following  charac- 
ters :  its  occurrence  where  the  cuticle  is  thin  and  delicate,  as  between 
the  fingers,  along  the  anterior  aspect  of  the  forearm,  upon  the  abdomen, 
thighs,  and  inside  of  the  feet;  small  size,  acuminate  shape,  and  isolated 
position  of  vesicles;  the  intermingling  with  the  vesicles  of  other  forms 
of  eruption,  as  papules  and  pustules,  and  the  presence  of  linear  scars 
and  abrasions  produced  by  the  scratching;  itching  most  intense  at 
night;  absence  of  fever;  absence  of  the  disease  from  posterior  aspect 
of  body  and  arms,  and  from  head  and  face.  Scabies  may  be  distin- 
guished by  the  vesicular  character  of  the  eruption  from  all  other  exan- 
theraatic  affections  except  eczema,  sudamina,  and  herpes.  Eczema  is 
most  common  on  the  scalp  and  face,  where  scabies  does  not  occur,  and 
unlike  scabies  its  vesicles  are  round  and  thickly  aggregated  in  clusters; 
in  eczema  there  is  a  smarting  or  prickling  sensation  very  diflerent  from 
the  intense  itching  of  scabies.  In  herpes  the  vesicles  are  large,  rounded, 
and  in  clusters,  and  attended  by  a  burning  or  pricking  sensation,  with 
but  little  itching.  This  eruption  in  sudamina  is  vesicular  and  discrete, 
as  in  scabies,  but  it  is  globular,  and  accompanied  by  no  itching  or  other 
local  symptoms. 

Treatment. — As  scabies  is  due  to  a  species  of  afarus  which  burrows 
in  the  epidermis,  it  can  only  be  treateil  successfully  by  measures  which 
destroy  this  animalcule.  If  it  bo  destroyed,  the  disease  gets  well  of 
itself.  Sulphur  has  been  employed  for  a  long  period  for  this  purpose, 
since  sulphurous  acid,  which  is  evolved  from  the  sulphur,  is  destructive 


856  SCABIES. 

to  the  nnimalcuie.  The  unguentum  sulphuris,  if  thoroughly  applied, 
Avill  rarely  fail  to  eradicate  scabies.  The  internal  use  of  sulphur  aids 
the  external  treatment,  since  a  portion  of  the  gas  "which  is  generated 
escapes  through  the  pores  of  the  skin.  The  chief  objection  to  the 
employment  of  sulphur  is  its  exceedingly  unpleasant  odor,  which  is 
noticeable,  however  disguised  by  perfume.  Sulphur  or  any  other  sub- 
stance employed  externally  has  more  effect  if  it  be  preceded  by  a  bath, 
which  softens  the  epidermis,  and  therefore  favors  the  entrance  of  the 
remedy  into  the  pores  of  the  skin  and  the  cuniculi. 

Helmerich's  ointment  is  very  effectual  in  the  treatment  of  scabies. 
It  consists  of  two  parts  of  sulphur,  one  of  carbonate  of  potassium,  and 
eight  of  lard.  "j\I.  Hardy  afterward  perfected  the  method,  so  as  radi- 
cally to  cure  the  disease  in  two  hours.  He  proceeded  in  the  folloAving 
manner:  The  patient  first  undergoes  a  friction  of  his  whole  body  for 
half  an  hour  with  soft  soap,  in  order  to  clcaruse  the  skin  and  break  up 
the  burrows ;  a  warm  bath  of  an  hour's  duration  follows,  during  which 
the  skin  is  thoroughly  rubbed,  in  order  to  complete  the  destruction  of 
the  burrows  ;  after  which  frictions  for  half  an  hour  and  upon  the  whole 
surface  are  practised  with  Helmerich's  ointment.  This  completes  the 
cure.  Out  of  four  hundred  patients  subjected  to  this  treatment,  only 
four  returned  to  the  hospital.""  ^ 

M.  Albin  Gras  experimented  with  different  substances,  in  order  to 
ascertain  their  relative  destructiveness  to  the  acarus.  The  following 
table  gives  some  of  the  results  of  his  experiments  : 

Immersed  in  pure  water  the  acarus  was  alive  after  three  hours. 

"  saline  water  the  acarus  moved  freely  after  three  hours, 

"  Goulard's  solution  ihe  acarus  lived  after  one  hour. 

''  olive,  almond,  or  castor  oil  the  acarus  lived  more  than  two  hours. 

"  lime-water  the  acarus  died  in  three-fourths  of  an  hour. 

•'  vinegar  "  "  twent}-  minutes. 

ii  alcohol  "  "  "  " 

"  turpentine        "  "  nine  " 

"  iodide  of  potassium  the  acarus  died  in  four  to  six  minutes. 

It  is  seen  that  vinegar,  lime-water,  alcohol,  turpentine,  and  iodide  of 
potassium  destroy  the  acarus  in  a  sliort  time.  They  may  be  employed 
in  the  same  manner  as  the  sulphur  ointment.  Camphor  is  also  destruc- 
tive to  this  animalcule,  and  the  linimentum  camphorse,  thoroughly 
applied,  is  a  good  remedy  for  uncomplicated  scabies. 

In  order  to  avoid  the  odor  of  sulphur,  which  is  so  offensive,  one  of 
the  following  ointments  may  be  employed,  if  the  patient  be  fastidious: 

R. — Unguent,  hydrarg.  ammoniat.       ....  ^j. 

Moschi  .      "  .         .         .^ gr.  ij. 

01.  lavendul. gtt.  ij. 

Ol.  amygdal. 3J.— Misce.* 

If  scabies  be  extensive  this  should  not  be  used,  a?  its  application  over 
considerable  area  might  endanger  salivation,  but  the  following,  which  is 

1  Stille's  Therapeutics,  etc.,  vol.  ii.  p.  61G.  '  From  Wilson. 


TEE  AT  ME  XT,  857 

recommended  by  Bazin,  and  is  said  to  cure  the  disease  with  three  appli- 
cations, may  be  used  instead : 

R. — Anthemis  pulv  "j 

Adipis,  [ aa   ij. —  Misce. 

Ol.  olivfe,  J 

In  cases  which  have  been  protracted,  and  in  which  ecthymatous  and 
other  secondary  eruptions  have  occurred,  the  scabies  can  ordinarily  be 
readily  cured,  while  the  other  eru])tions  remain  and  disappear  more- 
slowly.  A  knowledge  of  this  is  important,  since  the  sulphur  or  other 
ointment  employed  for  the  cure  of  scabies,  should  be  discontinued  when 
the  itching  ceases  and  vesicles  no  longer  appear,  and  tonic  or  other 
treatment  appropriate  to  cure  these  secondary  eruptions,  should  be 
employed  instead.  The  sulphur  ointment  continued  after  the  scabies 
is  cured  does  harm,  as  it  irritates  the  cuticle.  It  is  essential  in  the 
treatment  of  scabies  that  the  linen  be  frec^uently  changed. 


INDEX. 


••  A     B.  C."     cereal    milk,  analysis  of, 

A.     58 
Abdomen  indisea«e,  100 

in  rachitis,  127 
Abdominal  viscera  in  tuberculosis,  143 
Absce-s,  cervical,  145,  221 

pelvic,  in  constipation,  752 
strumous,  138,  145 
Acarus  scabiei,  854 
Acephalis,  415 

anatomical  characters,  415 
symptoms,  416 
prof^nosi-,  416 
Adenitis,  diplitlieritic,  307 
scarlatinous,  221 
strumous  138,  145 
Adhesions,  peritoneal,  a  cause  of  consti- 
pation, 752 
Alvine  discharges   a  cause  of  constipa- 
tion, 754 
in  disort-e,  101 
"  American  Swiss  "  infant  food,  analysis 

of,  58 
Anaemia  a  cause  of  chorea,  514 

moditication  of  mother's  milk  by,  39 
Analysis  of  milk,  57,  58 

of  infant  foods,  58 
Anenceplialus  (see  Acephalus). 
"  Anglo-Swiss  "  infant  food,  analysis  of, 

58 
Animal  heat  in  infancy,  99 
Anthelmintics,  770 
Anus,  occlu-ion  of,  750 
Apnoea  ne(niati,  71 
causes,  72 
treatment,  72 

artificial  respiration  in,  72 
Apoplexy  (see  Intercranial  hemorrhage). 
Appearance  in  disease,  91 
Arthritis  (see  Kheumalism). 
Artificial  feeding,  directions  for,  49,  57, 
61 
resjii ration,  72 
Ascaris  lumbricoides,  773 
Asphyxia  neonaii  (see  Apncea  neonati). 
caused  by  intestinal  worms,  766 
Asthma,    Kopp's    (see    Internal   convul- 
sions). 
Atelectasis,  605 
ac(|uired,  606 
cau-es,  606 
sympt'im-i,  607 
anatomical  characters,  607 
treatment,  608 


Atomizer  in  diphtheria,  322 

in  pertussis,  335 
Atrophy,  muscular,  531 
Attitude  in  disease,  93 


BABY  foods  (see  Infant  foods). 
"  Baby  Sup,"  analysis  of,  58 
Bacillus,  tubercle,  172 
Bathing  in  inlancy,  66 
Bile,  purpose  of,  60 
Bladder,  anatomy  of,  811 

irritability  of,  813 
'•  Blair's  "  wheat  f  »od,  analysis  of,  58 
Blood  in  diphtheria,  308 

poisoning  in  scarlet  fever,  243 
Blue  disea-e,  823 
Bone,  rachitic,  analysis  of,  114 
Bones,  modification  of,  by  rachitis,  113 

cranial,  in  rachitis,  116 
Brain,  absence  of,  415 
atrophy  of,  418 
composition  of,  414 
congestion  of,  429 
causes,  429 
symptoms,  431 
anatomical  characters,  431 
prognosis,  432 
treatment,  432 
disease  of,  413 
dropsy  of,  442,  449 
development  of,  414 
hypertrophy  of,  420 

pathological  anatomy,  420 
causes,  421 
symptoms,  421 
diagnosis,  423 
prognosis,  424 
treatment,  424 
imperfect,  417 
case  of,  417 
symptoms,  418 
prognosis,  418 
in  infancy,  18,  414 

membranes  of,  415 
hemorrhage  in  and  upon,  433 
fi'ver  (.see  Meninijilis). 
Breast  milk  (see  Milk,  human). 

indaniiiiHtion  of,  32 
Bright 's  (li-fase  (see  Nephritis). 
Bronchial  glands,  tubercles  of,  161,  168 

plithisis,  161 
Bronchitis,  593 
causes,  594 

(859) 


860 


INDEX. 


Bronchitis,  anatomical  characters,  594 
symptoms,  597 
duration,  599 
chronic,  599 
diagnosis,  599 
prognosis,  600 
treatment,  (500 
in  measles,  188,  191 
tubercular,  158 


CALCULUS,  vesical,  a  cause  of  enu- 
resis, 81-J 
Cancer,  aqueous,  of  infants,  673 
Cancrum  oris  [see  Gangrene  of  mouth). 
Capillary  bronchitis  in  measles,  191 
Caput  succedaneum,  73 
Cardiac  degeneration  in  diphtheria,  308 

malformations,  823,  834 
Care  of  mother  in  pregnancy,  19 
Caries,  vertebral,  551 
Cartilages  in  rachitis,  113 
Catarrhal  laryngitis,  559 
pharyngitis,  687 
pneumonitis,  609,  612 
Cellulitis,  strumous,  140 

scarlatinous.  221 
Cephahomatonia,  73 

Cephalalgia  in  meningeal  tubercles,  166 
Cerebral    hemnrrhage    (see    Intracranial 
hemorrliaite). 
tubercles,  167 
Cerebro-spinal  disease  a  cause  of  consti- 
pation, 754 
Cerebro-spinal  fever,  358 

etiology,  358 

non-contagiousness  of,  360 

sex,  363 

age,  363 

mode  of  commencement,  366 

symptoms,  364,  367 

pulse,  373 

temperature,  373 

respiratory  sy^^tem,  375 

cutaneous  system,  376 

urinary  organs,  376 

special  senses,  377 

nature,  380 

anatomical  characters,  382 

prognosis,  387 

diagnosis,  389 

treatment,  390 
Cerebro-spinal  system,  diseases  of,  413 

meningitis,  358 
Cheesy  pneumonitis,  614 
Chiek'enpox,  293 
Childhood,  duration  of,  19 

changes  of  organs  in,  19 
Cholera  infantum,  734 
Choleriform  diarrhoea,  734 

anatomical  characters  735 

nature,  738 

diagnosis,  739 

prognosis,  739 

treatment,  739 
Circulation,  changes  in,  at  birth,  18 


Circulatory  system  in  infancj',  96 

diseases  of,  823 
Clavicle  in  rachitis,  124 
Clothing  in  infancy,  67 
Colitis  in  childhood,  718 
Colostrum,  28,  33 

examination  of,  28 

constituents  of,  29,  33 

microscopic  appearance,  33 

purpose  of,  34 

injurious  effects  of,  on  infant,  35 

a  cause  of  diarrhoea,  724 
Colustrum  corpuscles,  33 
Condensed  milk,  64 
Congenital  hydrocephalus,  442 
Congestion  of  brain,  429 

of  spinal  cord  and  membranes,  545 
anatomical  characters, 

546 
symptoms,  546 
treatment,  546 

of  stomach,  704 
Conjunctivitis,  gonorrhoeal,  822 
Constipation,  750 

congenital,  750 

symptomatic,  750 

causes,  741 

idiopathic,  754 

symptoms,  755 

symptomatic  cases,  755 

idiopathic  cases,  756 

treatment,  759 

hygienic,  759 

therapeutic,  762 

in  intussusception,  788,  796 

cases  of  extreme,  756 

alternating  with  diarrhoea,  758 
Constitutional  diseases,  105 
Consumption  (see  Tuberculosis). 
Convulsions,  clonic  (see  Eclampsia). 

in  cerebral  tuberculosis,  167 

internal  (see Laryngismus  stridulus). 

in  pertussis,  330 

in  diphtheria,  310 

in  measles,  192 

in  scarlet  fever,  264 
Coryza,  556 

anatomical  characters,  557 

symptoms,  557 

prognosis,  557 

treatment,  557 

in  scarlet  fever,  228 

syphilitic,  180 

treatment,  186 
Cranial  bones  in  rachitis,  116 
Craniotabes  in  rachitis,  117 
Croup,  diphtheritic,  310 

false  (see  Larynojitis,  spasmodic). 

membranous,  567 

etiology  of,  567 

anatomical  characters,  571 

symptoms,  573 

diagnosis,  574 

prognosis,  575 

treatment,  576 

true  [see  Croup,  membranous). 


INDEX. 


861 


Croup,  in  measles,  192 

Croupous  pnenmonitis  609,  611 

Cryptorchia,  820 

Cutaneous  appearances  in  disease,  92 

diseases,  840 
Cyanosis,  823 

literature,  824 

sex, 826 

causes  of  cardiac  deformity,  826 

age,  827 

symptoms,  829 

prognosis,  833 

modes  of  death,  833 

heart  lesions  in,  835 

morbid  anatomy,  835 

etiolosry,  836 

treatment,  838 


DACTYLITIS,  strumous,  139 
syphilitic,  183 
Death  in  infancy,  23 

rate  in  infancy,  24 
Deformity,  hereditary  transmission  of,  22 

in  foetus,  due   to   maiernal   impres- 
sions, 20 
Dentition,  680 

putholos^ical  results  of,  681 

diagnosis,  683 

treatment,  684 

second,  685 

in  rachitis,  126 

in  syphilis,  184 

its  relation  to  diarrhoea,  724 
Dias;nosis  of  infantile  di>ea-es,  90 
Diarrhoea,   inflammatory  {see  Intestinal 
catarrh  of  inlanis). 

summer  (see  Enieio-coiitis). 

following  Constipation,  758 

a  cause  of  intussu.-ception,  7b8 

non-inrtammatory,  713 

causes,  714 

symptoms,  714 

anatomical  characters,  715 

prognosis,  716 

treatment,  716 
Diathetic  disea>es,  105 
Diet  a  cau-^e  of  rachitis,  109 

a  cause  of  emero-colitis,  724 

a  cause  of  infant  mortality,  27 

a  cau-e  of  constipation,  754 

of  mother  in  pregnane}',  19 

of  moth'-r  duiini:  lactation,  43 

elTects  of,  <>n  milk  secretion,  36 

of  infant,  49 
Digestion,  disorders  of,  697 
Digt'Stive  >ysiem  in  infancy,  100 

sei-reiioMs,  action  of,  60 
Diplitlieria,  295 

ago,  295 

incubative  period,  296 

nature,  297 

causes,  297 

anatomical  characters,  304 

symptoms,  309 

diagnosis,  314 


Diphtheria,  prognosis,  314 
cau^es  of  death,  315 
treatment,  316 
general,  318 
stimulants,  318 
tonics,  319 
local,  322 
preventive,  324 
of  complications,  315 
measles,  93 
scarlet  fever,  225,  254 
constitutional,  301 
primary,  297 
secondary,  297 
Diphtheritic  cn.up,  310 
gastritis,  708 
nephritis,  302,  311 
paralysis,  313,  324 
Dysentery  in  children,  747 
Dy;pepsia,  697 
Dysuria,  819 


I?AR,  scarlatinor.s  affections  of,  228 
J         strumous  affections  of,  141 
Eclampsia,  476 
causes,  476 

premonitory  stage,  477 
symptoms,  478 
anatomical  characters,  480 
diagnosis,  481 
proijnosis,  482 
treatment,  483 
in  cerebral  tubercles,  167 
in  diphtheria,  310 
in  measles,  192 
in  scarlet  fever,  228 
in  pertussis,  330 
Eczema,  847 

anatomical  characters,  848 
acute,  848 
chronic,  848 
etiology,  848 
varieties,  848 

rubrum,  849 
impeiiginosum,  849 
diagnosis,  850 
treatment,  850 
in  acute,  8>0 

constitutional,  850 
external,  851 
pruritus,  852 
in  chronic,  852 
Elixir  adjuvans,  103 
Eiiuitics  in  crou|),  588 
Emphysema  in  rachitis,  130 

ii»  tuberculosis,  160 
Em|)yemH,  651 
Enccphaloiolc,  74 
Encephalon,  tubcrclfs  in,  166 
Endocarditis  in  rhtnimaii-m,  400 

Ircatmeiil,  40-i 
Enteritis,  747 
Enteni  colitis,  718 
in  mna-le-',  192 
Enuresis,  81 1 


862 


INDEX 


Enuresis,  occurrpnce,  811 

etioloiiy,  822 

nervous,  818 

pro<;nosis,  814 

treatment,  815 
Eruptive  fevers,  188 
Erys  pelas,  404 

a,s;e,  406 

point  of  invasion,  406 

cause,  406 

premonitory  symptoms,  409 

symptoms.  409 

prognosis,  410 

duration,  410 

modes  of  death,  410 

patlioloirical  anatomy,  410 

treatment,  411 

in  nursiiii;  mdther,  32 

after  vaccination,  405 
Erythema,  idiopathic,  840 
simplex,  840 
intertrigo,  840 
la-ve,  841 

symptomatic,  841 
fugax, 841 
papuium,  841 
tuberculum,  841 
nodosum,  841 

prognosis,  841 

diagnosis,  841 

treatment,  842 

fugax  in  diphtheria.  312 
Erythematous  diseases,  839 
Exercise  in  infancy,  70 
Extractum  f^ancrealis,  61 
Eye,  strumous  affections  of,  148 

in  measles,  188 


FACIAL  paralysis,  538 
causes,  538 
symptoms,  539 
prognosis,  539 
treatment,  539 
Farinaceous  infant  foods,  58 
Fell  file    affections    in    nursing   mother, 

31 
Feeding,    improper,   a  cause   of   infant 
mortality,  27 
infant  {see  Infant  food). 
Femur  in  rachitis.  125 
Fever  and  ague  (.se«  Intermittent  fever). 
Fever,  malarial  (see  Intermittent  fever). 
Fibula  in  raciiitis,  125 
Fingers,  bulbous  enlargement  of,  92 
Foetus,   effects  of  matercal   impressions 
on,  20 
injury  of,  in  ntero,  22 
syphilis  in,  178 
Follicular  gastritis,  708 
Food,    improper,    a    cause    of    raciiitis, 
109 
quantity  required  (see  Diet),  51 
French  measles  (see  Rotheln) 
Fright  a  cause  of  chorea,  519 


GALACTOGOGUES,  44 
Galactorrhflja,  40 
Gangrene  of  mouth,  673 

anatomical  characters,  673 
age,  674 
causes,  674 
symptoms,  675 
diagnosis,  676 
prognosis,  676 
treatment,  677 
following  measles,  193 
Gastric  juice,  purpose  of,  60 
Gastritis,  704 
cause  705 
age,  705 
symptoms,  706 
anatomical  characters,  707 
diagnosis,  707 
prognosis,  707 
treatment,  708 
follicular,  708 
diphtheritic,  708 
Gastro-intestinal  hemorrhage,  781 
in  newborn,  781 
causes,  782 
purpuric,  783 

causes,  783 
local,  784 

causes.  784 
frequency,  784 
case  of,  784 
prognosis,  785 
treatment,  785 

regimenal,  785 
therapeuiic,  786 
Gelatine  as  an  infant  food,  65 
Genito-urinarv  diseases,  810 

organs  232 
"Gerber's  milk  food,"  analysis  of,  58 
Germ  cultivation,  198 
German  measles  (see  Rotheln). 
Glandular  system  in  struma,  137 

in  scarlet  fever,  221 
Glottis,  spasm  of  (Laryngismus  stridu- 
lus). 
Gonorrhoea  in  the  child,  821 
Growth  of  infants,  28 


HEMOPTYSIS     in    infant    tubercu- 
losis, 170 
"  Hawley's  Infant  Food,"  58 
Heart,  dilatation  of,  after  scarlet  fever. 
231 

malformations  of,  823 

lesions  in  rheumati.-m,  400 
Hemorrhage,  umbilical,  27 

intercranial,  433 

intestinal,  in  intussusception,  796 

gaslro-intcslinal,  781 
Hernia,  a  cause  of  constipation,  751 
Hip-joint  disease,  551 
Hives  (see  Urticaria). 
"Horlick's  Infant  Food,"  58 
"Hubbell's  Wheat  Food,"  58 


INDEX. 


863 


Human  milk  (see  Milk,  human). 
Humanized  cows'  milk,  62 
Humerus  in  rachitis  124 
Hydrencephaloceie,  74 
Elydrocephaliis,  acquired,  449 

cause-,  44'J 

anatomical  characters,  450 

sj'mptoms,  450 

prognosis,  452 

treatment,  452 
congenital,  442 

anatomical  characters,  442 

etiology,  445 

symptoms,  446 

diagnosis,  447 

prognosis,  448 

treatment,  448 
spurious,  470 

anatomical  characters,  378 

symptoms,  471 

diagnosis,  474 

prognosis,  474 

treatment,  475 
Hyperemia  in  nursing  women,  48 


ICTERUS  neonati,  91 
Idiocy,  congenital,  due  to  maternal 
impressions,  2 
Imitation  a  cause  of  chorea,  519 
Imperforate  rectum,  706 
"  Imperial  Granum,"  analysis  of.  58 
Indigestion,  697 
causes,  697 
symptr)m«,  699 
prognosis,  700 
diagnosis,  701 
treatment,  701 
Infancy,  17 

period  of,  17 
organs  in,  17,  18 
secretions  in,  17 
integument  in,  17 
appetite  in,  18 
thymus  gland  in,  18 
kidney  in,  18 
senses  in,  18 
mental  fuculiies  in,  18 
brain  in,  18 
stomach  in,  18 
mortality  of,  23 
siirns  of  disease  in,  90 
sleep  during,  69 
exercise  in,  70 
artificial  food  in,  57 
Infant  morlality,  2^,  24 

period  of  greatest,  23 
cause*,  24 

inlerfuil  malformations,  24 
feebleness  of  syslcm,  24 
hereditary  disease,  24 
infectioUH  diseases,  25 
antihygienic  conditions,  25 
exposure  to  cold,  26 
improper  feeding,  27 
prevention  of,  25 


Infant  growth,  28 
care  of,  63 
bathing,  66 
clotliing,  66 
food,  49 

analysis  of,  58 
quantity  required,  51 
artificial,  57 
hygiene,  66 
therapeutics,  103 
weight  of,  28 
Infantile  paralysis,  528 
symptoms,  530 
prognosis,  532 
progress,  532 
etiology,  533 

anatomical  chnracters,  53C 

diagnosis,  5  56 

prognosis,  536 

treatment,  537 

Injury  to  foetus  in  utcro,  22 

to  mother  a  cause  of  mi-carriage,  22 
Tnteiiumnnt,  character  of,  in  infancy,  17 
Intercranial  hemo-rhage,  433 
cau>es,  433 

anatomical  characters,  434 
meninircal,  435 
cerebral,  426 
symptom*,  437 
diai^nosis,  440 
-jirog'iosis,  441 
treatment,  441 
Intermittent  fever,  342 
causes,  342 

incubative  period,  343 
symptoms,  343 
treatment,  346 
Internal  convulsions,  504 
causes,  505 

anatomical  characters,  507 
sympton)s,  507 
diagnosis,  509 
prognosis,  509 
modes  of  death,  509 
treatment,  510 
Intestinal  catarrh  of  inftncy,  718 
etioloiry,  720 
age,  726 
dentiti(m,  726 
symptom-,  726 
anatomical  characters,  730 
diagnosis,  734 
progn  'Sis,  734 
treatment,  730 
curaiivc,  740 
medicinal,  741 
cxtt'ituil,  746 
dejections,    morbid    indications    in 

101 
displacements,  751,  787 

a  cause  of  constipation,  751 
secretions,  GO 
worms,  765 

Hscaris  liimbricoides,  706 
oxvuris  vcrmiciilaris,  767 
twnia,  768 


864 


INDEX. 


Intestinal   worms,  tricocephalus  dispar, 
771 
causes,  773 
symptoms,  773 
diajinosis,  776 
prognosis,  776 
treatment,  776 
Intestine,  displacement  of,  751 
hemorrhage  from,  781 
invagination  of,  787 
intussusception  of,  787 
obstruction  of,  750 
in  tiiherciilrtsis,  173 
irritation    of,    a    cause    of   chorea, 
520 
Intussusception,  787 

without  symptoms,  787 

post-mortem  form,  787 
with  symptoms,  788 
previous  health,  788 
causes,  788 
sex,  788 
age,  789 
seat,  7'.  10 

pathological  anatomy,  790 
small  intestine,  700 

cases,  790 
large  intestine,  793 
incomplete,  794 
symptoms,  796 
d"iagnosis,  797 
duration,  798 
prognosis,  798 
modes  of  death,  800 
treatment,  801 

by  injection,  801 

by  inflation,  804 

laparotomy,  807 

Invaerination  of  the  intestine,  787 

Itch  (see  Scabies). 


JAUNDICE  of  newborn  (see  Icterus 
neonati)  a  cause  of  umbilical  hemor- 
rhage, 89 
Joints,  inflammation  of  {see  Eheumatism) 


KEASBEY  and  Mattison's  infant  food, 
58 
Keratitis,  strumous  (see  Strumous  oph- 
thalmia), 
herpetic,  149 

phlyctenular,  149 
vascular,  149 
parenchymatous,  151 
symptoms,  151 
non-yascular,  151 
duration,  152 
causes,  152 
treatment,  152 
Kidney,  congenital  cystic,  degeneration 
of,  18 
inflammation  of  (see  Nephritis). 
in  racliiiis,  128 
uric  acid  infarctions  of,  810 


Kopp's  asthma  (see  Laryngismus  stridu- 
lus). 
Kyphosis  in  rachitis,  121 


LACTATION,  28 
abnormal,  41 
care  of  mother  during,  29 
communication  of  disease  by,  45 
diet  during,  4.3 
directions  for,  28 
hinderances  to,  29 
tuberculosis,  30 
erysipelas,  32 
mastitis,  32 
menstruation  during,  47 
termination  of,  Go 
Lactic  acid  as  a  cause  of  rachitis,  110 
Lactometer,  46 
Lactoscope,  4(j 

Laryngismus  stridulus  (see  Convulsions, 
internal), 
in  rachitis,  127 
Laryngitis,  catarrhal,  559 
symptoms,  559 
chronic,  560 

anatomical  charafters,  561 
treatment,  5(51 
pseudo-membranous      (see      Croup, 

membranous), 
spasmodic,  562 
causes,  562 
symptoms,  562 
anatomical  characters,  563 
diagnosis,  563 
prognosis,  564 
treatment,  564 
tubercular,  157 
Laxatives  in  diarrhoea,  717 
Liebig's  infant  food,  preparation  of,  63 
analysis  of,  58 
in  constipation,  760 
Ligaments  in  rachitis,  127 
Liver  in  rachitis,  127 
Lividity  of  newborn,  91 
Lockjaw,  485 
Lordosis  in  rachitis,  126 
Lung,  inflammation  of  (,9ee Pneumonitis), 
in  tuberculo-is,  158,  169 
cedcma  of,  in  diphtheria,  315 


MALE  fern  in  taenia,  780 
Maliijnant  scarlet  fever,  217 
Mastitis,  32 

Maternal  impressions,  effects  on  foetus,  20 
Maxilla  in  rachitis,  121 
Measles,  188 

etiology,  188 

symptoms,  188 

complications,  191 

anatomical  characters,  193 

nature,  194 

diagnosis,  194 

prognosis,  195 

treatment,  195 


INDEX. 


865 


Measles  complicating  rachitis,  132 
Meconium,  17 

composition  of,  17 
Mellin 's  food,  58 

Membranous   croup    {see    Croup,    mem- 
branous). 
Menine;eal  hemorrhage  [see  Intercranial 
hemorrhage), 
tuberculosis,  166 
congestion,  545 
Meninges,  congestion  of,  545 
hemorrhage  into,  433 
tubercles  in,  166 
Meningiti-",  452 

tubercular,  453 

non-tubercular,  453 

age,  454 

pathological  anatomy,  455 

causes,  459 

symptom*,  461 

diagnosis,  466 

prognosis,  466 

treatment,  468 

cerebro-spinal     (see    Cerebro-spinal 

fever). 
a  cause  of  constipation,  754 
Meningocele,  74 

Menstruation  in  lactation,  38,  47 
Mental  excitement  in  pregnancy,  20 

impressions,  effects  of,  on  foetus,  20 
Mercury  in  syphilis,  185 
Mierocephalus,  418 
Milk,  asses',  59 
goat's,  59 
condensed,  64 
cow's,  35 

specific  gravity  of,  35 

modified  by  feeding,  36 

cun-lituenis  of  35 

analysis  of,  57 

compared  with  human,  59 

improper,  a  cause  of  diarrhoea, 

725 
humanized,  62 
condensed,  64 
human 

analysis  of,  35,  57 
abnormal  secretion,  41 
bacilli  in,  46 
constituents  of,  57 
examination  of,  28,  45 
excessive  secretion  of,  40 

causes,  40 
modification     by    retention     in 
breast,  36 
age,  37 

maternal  impressions,  37 
pregnancy,  38 
diet,  36 

venereal  excess,  39 
phthisis,  39 
anicmia,  39 
syphilis,  39 
nervous  disorders,  39 
medicinal  substances,  39 
pus  in,  32 


Milk,  human,  differences  in  quality,  39 
quantity  required  by  infants,  52 
scanty  secretion  of,  40 
causes,  40 

hyperaemia,  41 
atrophy  of  breast, 
41 
treatment,  41,  43 
Miscarriage,  prevention  of,  19 

causes  of,  19,  22 
Morbiili  (see  Mea«le«). 
Morbus  caenileus,  823 
Mortality  of  early  life,  23 
Mother,  care  of,  in  pregnancy,  19 
diet  of,  in  pregnancy,  19 
care  of,  in  lactation,  29 
Mouth,  gangrene  of,  673 
after  measles,  193 
inflammation  of  (see  Stomatitis). 
Mucous  patches  in  syphilis,  180 
Muguet  (see  Thrush). 
Mumps  {see  Parotiditis). 
Muscular  atrophy,  531 
Myelitis  a  cause  of  constipation,  754 


NECROSIS,  treatment,  324 
infantile  (see  Gangrene  of  mouth). 
Nephritis,  232 

parenchymatous,  2.34 
'pathology  of,  234 
interstitial,  236 

patholotcv  of,  236 
symptoms,  237 
treatment,  259 
Nephritis,  diphtheritic   302 

scarlatinous,  212 
Nervous  cough,  660 

treatment,  661 
system  in  disease,  102 
Nestle's  food,  analysis,  58 
Nettle-rash,  845 

Newborn,  asphyxia  of  (see  Apnoea  neo- 
nati). 
septicemia  of,  83 
weight  of,  28 
Nipple,  depressed,  29 

treatment  of,  29 
fissure  of,  30 
Noma  (see  Gangrene  of  mouth). 
Nurse,  selection  of,  39-44 
Nursing  (see  Lactation). 
frequency  of,  39-48 


OBRTKTKICAL  scarlet  fever,  208 
(Edema  gloltidis  in  scarlet  fever,  223 
general,  in  scarlet  fever,  237 
(Esophagilis,  696 

anatomical  characters,  696 
symptoms,  697 
Oidium  albicans,  669 
Ophthalmia,  herpetic,  149 
symptoms,  149 
duration,  149 
diagnosis,  149 


56 


866 


INDEX. 


Ophthalmia,  herpetic,  cause?,  149 
prognosis,  150 
treutmenl,  loO 
parenchymatous,  151 
symptoms,  151 
duration,  152 
treatment,  152 
phlyctenular  (-tee  Herpetic), 
in  measles,  l-id 
neonati,  77 
causes,  77 
symptoms,  78 

hlenorrhoeal  form,  78 
catarrhal  fnrm,  78 
treatment,  79 
strumous,  148 
Ophtlirtlmoscope  in  cerebral  diseases,  413 
Osseous  system  in  rachitis,  113 
Osteosclerosis,  128 
Otitis  in  scarlet  fever,  228 
treatment,  256 
in  struma,  141 
Otorrhcea  in  scarlet  fever,  228 
treatment,  256 
in  struma,  141 
Osyuris  vermicularis,  767 


PAIN  as  an  indication  of  disease,  102 
Pancreatic  juice,  purpose  of,  60 
Papular  cutaneous  disease,  846 

eczema,  849 
Paralysis,  facial,  538 
diphtheritic,  313 

treatment,  324 
in  cerebral  tuberculosis,  167 
infantile,  528 

with  pseudo-hypertrophy,  540 
symptoms,  540 
anatomical  characters,  542 
causes,  543 
prognosis,  543 
treatment,  543 
Parotid  gland  in  infancy,  63 
Parotiditis,  339 
nature,  340 
diagnosis,  340 
treatment,  340 
Parotitis  (.see  Parotiditis). 
Pemphigus  in  syphilis,  181 
Peptonized  milk,  61 

method  of  preparing,  61 
Pericarditis  in  scarlet  fever,  230-265 
Pericardium,  tubercles  of,  163 
Period  of  greatet-t  infant  mortality,  23 
Periostitis,  strumous,  139 

treatment,  147 
Peripharyngeal  abscess,  690 
age,  690 
cause,  690 

anatomical  characters,  691 
symptoms,  692 
diagnosis,  694 
treatment,  695 
Peritonitis  a  cause  of  constipation,  352 
tubercular,  752 


Pertussis,  325 
age,  326 
causes,  326 

pathological  anatomy,  327 
symptoms,  328 
Complications,  330 
diagnosis,  333 
prognosis,  834 
treatment,  335 
Pharyngitis,  catarrhal,  687 

anatomical  characters,  687 
causes,  688 
symptoms,  688 
prognosis,  688 
diagnosis,  689 
treatment,  689 
diphtheritic,  304-310 

treatment,  322 
scarlatinous,  212-254 
Pharynx,  ulceration  of,  in  scarlet  fever, 

223 
Phimosis  a  cause  of  dysuria,  820 
Phthisis  (.see  Tuberculosis), 
bronchial,  161 
in  nursing  mother,  39 
Pleura,  tuberculosis  of,  160 
Pleurisy  (.see  Pleuritis). 
Pleuritis,  622 

frequency,  623 
causes,  623-628 
anatomical  characters,  629 
plastic,  630 
sero-fibrinous,  630 
purulent,  631 
hemorrhagic,  632 
symptoms,  636 
physical  .signs,  639 

palpation,  639 
percussion,  640 
a;isculiation,  640 
diagnosis,  642 
prognosis,  644 
treatment,  646 
external,  647 
internal,  647 
thoracentesis,  657 
empyema,  651 

operating,  mode  of,  for  serofibrinous 

exudation,  652 

for  empyema,  653 

admission  of  air,  655 
injury  to  lung  by  nee- 
dle', 656 
washing     out    pleural 

cavity,  657 
tent  and  drainage-tube, 
659 
exsection  of  ribs,  660 
Pneumonia  (.see  Pneumonitis). 
Pneumonitis,  609 
lobar,  609 
croupous,  609 
interstitial,  609 
catarrhal,  (509 
causes,  600 
anatomical  characters,  611 


INDEX. 


867 


Pneumonitis,  chee.«y,  614 

symptoms,  615 

physical  sisins,  617 

diagnosis,  618 

prognosis,  619 

treatment,  620 
catarrhal,  620 
croupous,  020 
local,  622 

in  measles,  192 

in  pertu-sis,  331 

in  rheumatism,  403 
Post-mortem  gastric  softening,  709 
Pott's  disease,  551 
Pregnancy,  care  of  mother  in,  19 

diet  of  mother  in,  19 

exercise  of  mother  in,  19 

disease  (>f  mother  in,  20 
intermittent  fever,  20 
syphilis  in,  20 

changes  in  millc  of  mother  in,  38 
Prolapsus  recti,  758 

Pseudo-membranous   croup    {see    Mem- 
branous croup). 
Psorophthalmia,  strumous',  141 
Pulse  in  health,  97 

in  disease,  98 

in  infancy,  97 

influenced  by  excitement,  98 
Pus  in  milk,  32 


pACHITIS,  105 
li         frequency,  105 
age,  107 
causes,  109 

artificial  production,  110 
anatomical  characters,  first  stage,  1 12 

path'ilogy  of,  115 
anatomical  characters,  second  stage, 
115 
cranium  in,  116 
craniotabes,  117 
vertebiic  in,  120 
kyphosis  in,  121 
lordosis  in,  121 
scoliosis  in,  121 

bones  of  upp'ir  extremity  in,  124 
pelvis  in,  124 

bones  of  lower  extremity  in,  125 
soft  tissues,  127 
anatomical  characters,   third  stage, 
128 
gymittoms,  129 

complications  and  sequelte,  130 
diagnosis,  131 
prognosis,  132 
treatment,  133 
Radius  in  rachitis,  124 
Rectum,  hemorrha'^e  from,  781-796 
imperforate,  750 
occlusion  of,  750 
prolap-^Ui  of,  758 
stenosis  of,  7;')0 
Remittent  fever,  347 

symptoms,  847 


Remittent  fever,  diagnosis,  348 

treatment,  348 
Respiration  in  infancy,  94 
in  health,  91 
in  disease,  95 
Rheumatism,  acute,  398 
causes,  399 
symptoms,  399 
duration,  401 
prognosis,  401 
diagnosis,  402 
treatment,  402 
pneumonitis  in,  403 
endocarditis  in,  400 
treatment,  403 
a  cause  of  chorea,  514 
in  scarlet  fever,  229-265 
Ribs,  changes  in,  in  rachitis,  122 
exsection  of,  in  pleuritis,  060 
Rickets  {see  Rachitis). 
Ridge's  infant  food,  analysis  of,  58 
Robinson's  patent  barle}',  analysis  of,  58 
Roseola,  843 

idiopathic,  843 

varieties,  843 
symptomatic,  843 
varieties,  843 
symptoms,  843 
causes,  844 
prognosis,  844 
diagnosis,  844 
treatiient,  844 
syphilitic,  180 
R6theln,265 
history,  266 
premonitory  stage,  267 
symptoms,  268 
tegumentary  system,  268 
respiratory  system,  269 
digestive  system,  269 
pulse,  270 
temperature,  270 
complications,  270 
prognosis,  270 
nature,  271 

incubative  period,  271 
Round  worm  (intestinal),  765 
Rubeola  (see  Measles). 


SALIVA,  purpose  of,  60 
Santonin,  European,  in  worms,  777 
Savory  ifc  Moore's  infant  food,  analysis,  58 
Scabies,  854 
cause,  854 
diagnosis,  855 
treatment,  855 
f^ippula  in  rachitis,  124 
iScarlatina  {see  Scarlet  fever). 
Scarlatinous  nephritis,  232-259 
Scarlet  fever,  197 

history,  197 
etiology,  197 
incubative  period,  202 
contatiiousness  of,  204 
variations  in  type,  204 


868 


INDEX. 


Scarlet  fever,  surgical,  205 
obstetrical,  205 
age,  210 

clinical  facts,  211 
symptoms,  213 
malignant  type,  217 
irregular  forms,  219 
complications,  220 
sequelfc,  220 
adenitis  in,  221 
nephritis  in,  232 
anatomical  characters,  238 
diagnosis,  240 
prognosis,  241 
treatment,  244 

prophylactic,  244 
hygienic,  247 
therapeutic',  258 
in  mild  cases   248 
in  ordinary  and  severe,  249 
antiseptic,  253 
complications  and  sequelaj, 
254 
Scoliosis  in  rachitis,  121 
Scrofula,  135 
causes,  136 

anatomical  characters,  187 
symptoms,  140 
prognosis,  142 
treatment,  143 

prophylactic,  143 
curative,  143 
ophthalmia  in,  148 
Secretions  in  infancy,  17 
Septicaemia  in  diphtheria,  301-307 
in  newborn,  83 
in  scarlet  fever,  243 
Skin,  appearance  in  syphilis,  180 
diseases  of,  840 
in  disease,  92 
in  infancy,  17 
Smallpox,  274 

Solvents  of  pseudo-membrane,  322-579 
Spasmodic  laryngitis,  562 
Spasm  of  glottis  (see  Laryngismus  stri- 
dulus). 
Spigelia  in  intestinal  worms,  777 
Spinal  cord,  congestion  of,  545 

diseases  of,  413-544 
Spina  bifida,  547 

anatomical  characters,  547 
diagnosis,  549 
prognosis,  549 
treatment,  549 
Spine  (see  Thrush). 
Spleen  in  rachitis,  127 
Spurious  hydrocephalus,  470 
Starch,  digestion  of,  by  infants,  62 
St.  Guy's  dance  (see  Chorea). 
Stomach,  congestion  of,  704 
diseases  of,  697 
inflammation  of,  704 
post-mortem  softening  of,  709 
in  tuberculosis,  163 
Stomatitis,  663 
simple,  663 


Stomatitis,  catarrhal,  663 
symptoms,  664 
appearance,  664 
treatment,  664 
ulcerous,  665 
causes,  665 
symptoms,  666 
prognosis,  666 
treatment,  666 
aphthous,  667 
causes,  647 
symptoms,  667 
diagnosis,  668 
prognosis,  668 
treatment,  668 
Strabismus  a  sign  of  infant  disease,  92 
Strophulus,  846 
varieties,  846 
appearance,  846 
treatment,  847 
Struma  {see  Scrofula). 
Strumous  ophthalmia,  148 
duration,  149 
diagnosis,  147 
causes,  149 
prognosis,  150 
treatment,  150 
St.  Vitus's  dance  (see  Chorea). 
Syphilis,  177 

etiology,  177 

contagiousness  of,  177 

clinical  history,  178 

congenital,  178 

age  of  appearance,  179 

in  foetus,  178 

visceral  lesions  in,  181 

osseous  lesions  in,  182 

prognosis,  184 

treatment,  185 

in  nursing  mother,  31 

in  lactation,  39 

communicated  by  lactation,  45 


T^NIA,  768 
solium,  769 

saginata,  770 

medico-canellata,  770 

elliptica,  770 

cucumerina,  770 

bothriocephalus,  771 

tricocephalus  disjiar,  771 

treatment,  779 
Tape-worm  (see  Tsenia). 
Teeth  in  rachitis,  126 

in  syphilis,  184 
Teething  [see  Dentition). 
Temperature,     almosjiheric    relation    to 
diarrhoea,  720 

in  disease,  99 

in  infants,  99 
Tetanus  infantum,  485 

cnmmencemcnt,  487 

frequency,  488 

causes,  489 

symptoms,  498 


INDEX. 


869 


Tetanus,  mode  of  death,  500 
prognosis,  500 
duration  in  fatal  cases,  500 
-diagnosis,  501 
treatment,  502 
Therapeutics,  infantile,  103 
Thoracentesis, 
Thorax  in  tuberculosis,  170 

in  rachitis,  123 
Thread-worms,  767 
Thrombosis  in  cranial  sinuses,  424 

anatomical  characters,  425 
causes,  427 
symptoms,  427 
diagnosis,  428 
prognosis,  428 
treatment,  428 
of  umbilical  vein,  83 
Thrush,  6ti9 

anatomical  characters,  669 
symptoms,  670 
causes,  671 
diagnosis,  671 
prognosis,  671 
treatment,  672 
Tibia  in  rachitis,  125 
Toxaemia,  diphtheritic,  301-307 
Tracheotomy,  575 
statistics  of,  575 
in  croup,  591 
directions  for,  591 
instruments  for,  592 
Tricocephalus  dispar,  771 
Trismus  {see  Tetanus  infantum). 
Tubage  in  membranous  croup,  589 
Tubercle,  anatomical  characters  of,  156 

bacillus,  153-172 
Tubercular  laryngitis,  157 

pneumonitis,  617 
Tuberculosis,  153 
etiology,  853 
contagiousness,  155 
anatomical  characters,  156 
symptoms,  165 
physical  signs,  169 
lungs,  169 
pleura,  171 
stomach,  172 
intestines,  173 
diagnosis,  172 
prognosis,  175 
ireatment,  175 

prophylactic,  175 
curative,  176 
in  nursing  mother,  30 
Typhoid  fever,  348 
causes,  349 

anatomical  characters,  8'>0 
incubative  period,  351 
symptoms,  353 
complications,  353 
diagnosis,  354 
duration,  355 
prognosis,  356 
treatment,  356 


ULNA  in  rachitis,  124 
Umbilical  curd,  management  of,  82 
vein,  thrombosis  of,  83 
treatment,  86 
phlebitis  of,  83 
granulations,  87 
fungus  (see  Umbilical  granulations). 

treatment,  87 
hemorrhage,  87 
causes,  88 
symptoms,  89 
prognosis,  90 
treatment,  90 
Umbilicus,  diseases  of,  82 
inflammation  of,  86 
causes,  86 
prognosis,  86 
treatment,  86 
ulceration  of,  86 
Uraemia  in  scarlet  fever,  237 
treatment,  259 
diphtheritic,  311 
Uric  acid  infarctions,  810 
Urine,  extreme  acidity  of,  810 

a  cause  of  enuresis,  812 
treatment,  810 
incontinence  of,  811 
excessive   amount,  a  cause  of  enu- 
resis, 812 
Urticaria,  845 

app'earance,  845 
causes,  845 
prognosis,  845 
diagnosis,  845 
treatment,  845 
Uterine  irritation  a  cause  of  chorea,  514 


VACCINATION  (.see  Vaccinia). 
Vaccine  virus,  292 
Vaccinia,  283 

history,  284 

appearances,  286 

sj'mploms,  286 

anomalies,  287 

complications,  287 

sequela;,  289 

revaccination,  289 

erysipelas  in,  405 

virus,  selection  of,  292 
Varicella,  293 

symptoms,  293 

diagnf)sis,  294 

prognosis,  294 

treatment,  294 
Variolii,  274 

incubative  period,  274 

stage  of  invasion,  275 
eruptive,  275 
desiccativo,  277 

mode  of  death,  278 

anatomical  characters,  27tf 

prognosis,  2H0 

diagnosis,  280 


870 


INDEX, 


Variola,  treatment,  281 

mistaken  for  measles,  195 
Varioloid,  278 
Vein,  umbilical,  phlebitis  of,  83 

thrombosis  of,  83 
Venereal  excess,  etfects  of,  on  milk,  39 
Vermifuges,  776 
Vertebral  caries,  551 

causes,  551 

symptoms,  553 

diagnosis,  554 

prognosis,  554 

treatment,  555 
VertebriB  in  rachitis,  120 
Vibriones  bacilli  in  human  milk,  46 
Virus,  vaccine,  292 
Visceral  lesions  in  syphilis,  181 
Voice  in  disease,  93 
Volvulus,  751 

case  of,  755 
Vomiting  in  constipation,  755 


Vomiting  in  meningeal  tuberculosis,  166 

in  intussusception,  796 
Vulvitis,  821 

aphthous,  821 

etiology,  821 

treatment,  822 


WEANING,  65 
menstruation  in  mothers  as  an  in- 
dication for,  88 
Weight  of  infants,  28 
Wetnurses,  selection  of,  39 

communication  of  disease  by,  45 
White  softening    of    intestinal   mucous 

membrane,  709 
Whooping-cough  (see  Pertussis). 
Worms,  765 

intestinal,  as  a  cause  of  constipation, 

752 
as  a  cause  of  intussusception,  788 


LEA  BROTHERS  S  CO.'S 

CLASSIFIED  CATALOGUE 


OF 


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A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
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NEILL,  JOJETN,  M.  J).,   and  SMITH,  F,  G.,  M.  !>., 

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Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

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one  12mo.  volume  of  81G  page.s,  with  370  illustrations.     Cloth,  $3.25;  leather,  $3.75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


4  Lea     Brothers  &  Co.'s  Publications — i>ictiouane». 

BILLINGS,  J.  S.f  A,  M.,  M.n.,  LL,  D.,  Harv,  and  Edin,, 

Member  National  Academy  of  Sciences,  Surgeon  U.  S.  A.,  Etc. 

A  MEDICAL  DICTIONARY,  including  English,  French,  German,  Italian 
and  Latin  Technical  terms  Used  in  Medicine  and  the  Collateral  Sciences.  By  John  S. 
Blllings,  a.  M.,  M.  D.,  LL.  D. 

WITH  THE  COLLABORATION  OF 

FRANK  BAKER,  M.  D.,  WASHINGTON  MATTHEWS,  M.D., 

JAMES  M.  FLINT,  M.D.,  H.  0.  YARROW,  M.  D., 

R.  LORINI,  M.D.,  W.  T.  COUNCILMAN,  M.  D., 

S.  M.  BURNETT,  M.  D.,  WILLIAM  LEE,  M.D., 

J.  H.  KIDDER,  M.  D.,  C.  S.  MINOT,  M.D. 

In  press. 

nVNGLISONy  BOBLET,  M.D., 

Late  ]\ofessor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON ;  A  Dictionary  of  Medical  Science :  Containing 
a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pliarmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulae  for  OflScinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Eichakd  J.  Dunglison,  M.  D.  In  one  very  large  and 
handsome  royal  octavo  volume  o:  1139  pages.  Cloth,  $6.50;  leather,  raised  bands,  $7.50; 
very  handsome  half  Russia,  raised  bands,  '" 


About  the  first  book  pnrehased  by  the  medical 
student  is  the  Medical  Dictionary.  The  lexicon 
explanatory  of  technical  terms  is  simplv  a  sine  qua 
non.  In  a  science  so  extensive  and  with  such  col- 
laterals as  medicine,  it  is  as  much  a  necessity  also 
to  the  practising  physician.  To  meet  the  wants  of 
students  and  most  physicians  the  dictionary  must 
be  condensed  while  comprehensive,  and  practical 
while  perspicacious.  It  was  because  Dunglison's 
met  these  mdications  that  it  became  at  once  the 
dictionary'  of  general  use  wherever  medicine  was 
studied  in  the  English  language.  In  no  former 
revision  have  the  alterations  and  additions  been 
80  great.  The  chief  terms  have  been  set  in  black 
letwr,  while  the  derivatives  follow  in  small  caps; 
»n  arrangement  which  greatly  facilitates  reference. 
— Cincinnati  Lancet  and  Clinic,  Jan.  10,  1874. 

A  book  of  which  every  American  ought  to  be 
proud.     When  the  learned  author  of  the  work 


passed  away,  probably  all  of  us  feared  lest  the  book 
should  not  maintain  its  place  in  the  advancing 
science  whose  terms  it  defines.  Fortunately,  Dr. 
Richard  J.  Dunglison,  having  assisted  his  father  in 
the  revision  of  several  editions  of  the  work,  and 
having  been,  therefore,  trained  in  the  methods 
and  imbued  with  the  spirit  of  the  book,  has  been 
able  to  edit  it  as  a  work  of  the  kind  should  be 
edited — to  carry  it  on  steadily,  without  jar  or  inter- 
ruption, along  the  grooves  of  thought  it  has  trav- 
elled during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and 
carried  through,  it  is  only  necessary  to  state  that 
more  than  six  thousand  new  subjects  have  been 
added  in  the  present  edition. — Philadelphia  Medical 
Times,  Jan.  3,  1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Oazette. 


SOBLYN,  RICH  Ann  J).,  M.  D, 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 
Sciences.  Revised,  with  numerous  additions,  by  Isaac  BLays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.     Cloth,  $1.50 ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  MiX^.— Southern 
Medical  and  Surgical  Journal.  

STUDENTS'  SEMIES  OF  MANUALS, 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine 
and  Surgery,  written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size 
12mo.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price.  The  following  vol- 
umes are  now  ready :  Treves'  Manual  of  Surgery,  by  various  writers,  in  three  volumes, 
each,  $2 ;  Bell's  Comparative  Physiology  and  Anatomy,  $2 ;  Gould's  Surgical  Diagno- 
ds,  $2 ;  Robertson's  Physiological  Physics,  $2 ;  Bruce's  Materia  Medica  and  Therapeu- 
tics {4th  edition),  $1.50;  Power's  Human  Physiology  (2d  edition),  $1.50 ;  Clarke  and 
Lockwood's  Dissectors'  Manual,  $1.50 ;  Ralfe's  Clinical  Chemistry,  $1.50 ;  Treves' 
Surgical  Applied  Anatomy,  $2 ;  Pepper's  Surgical  Pathology,  $2 ;  and  Klein's  Elements  of 
Histology  (M  edition),  $1.50.  The  following  is  in  press:  Pepper's  Forensic  Medicine. 
For  separate  notices  see  index  on  last  page. 

SERIES  OF  CLINICAL  MANUALS, 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the 
profession  with  a  collection  of  authoritative  monographs  on  important  clinical  subjects 
m  a  cheap  and  portable  form.  The  vohimes  will  contain  about  550  pages  and  will  be 
freely  illustrated  by  chromo-lithograplis  and  woodcuts.  The  following  volumes  are 
now  ready:  Carter  &  Frost's  Ophthalmic  Surgery,  $2.25;  Hutchinson  on  Syphilis, 
$2.25 ;  Ball  on  the  Rectum  and  Anus,  $2.25 ;  Marsh  on  the  Joints,  $2 ;  Owen  on  Surgical 
IHseases  of  Children,  $2 ;  Morris  on  Surgical  Diseases  of  the  Kidney,  $2.25 ;  Pick  on 
Fractures  and  Dislocations,  $2;  Butlin  on  the  Tongue,  $3.50;  Treves  on  Intestinal 
Obstruction,  $2;  and  Savage  on  Insanity  and  Allied  Neuroses,  $2.  The  following  are  in 
active  preparation:  Broadbent  on  the  Pulse,  and  Lucas  on  Diseases  of  the  Urethra, 
For  separate  notices  see  index  on  last  page. 


Lea  Brothers  &  Co.'s  Publications — Anatomy.  5 

GRAY,  MBNItY,  F.  B.  S., 

Lecturer  on  Anatomy  at  St.  Oeorge's  Hospital,  London. 

Anatomy,  Descriptive  and  Surgical.  The  Drawings  by  H.  V.  Carter,  M.  D., 
and  Dr.  WESXiiAcoTT.  The  dissections  jointly  by  the  Author  and  Dr.  Carter.  With 
an  Introduction  on  General  Anatomy  and  Development  by  T.  Holmes,  M.  A.,  Surgeon  to 
St.  George's  Hospital.  Edited  by  T.  Pickering  Pick,  F.  R.  C.  S.,  Surgeon  to  and  Lecturer 
on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Royal  College  of 
Surgeons  of  England.  A  new  American  from  the  eleventh  enlarged  and  improved  London 
edition,  thoroughly  revised  and  re-edited  by  William  W.  Keen,  M.  D.,  Professor  of 
Anatomy  in  the  Pennsylvania  Academy  of  the  Fine  Arts,  etc.  To  which  is  added  the 
second  American  from  the  latest  English  edition  of  Landmarks,  Medical  and  Surgi- 
cal, by  Luther  Holden,  F.  R.  C.  S.  In  one  imperial  octavo  volume  of  1098 
pages,  with  685  large  and  elaborate  engravings  on  wood.  Price  of  edition  in  black : 
Cloth,  $6 ;  leather,  $7 ;  half  Russia,  $7.50.  Price  of  edition  in  colors  (see  below) : 
Cloth,  $7.25, •  leather,  $8.25 ;  half  Russia,  $8.75. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  In  this  edition  a  new  departure 
has  been  taken  by  the  issue  of  the  work  with  the  arteries,  veins  and  nerves  distinguished 
by  difTerent  colors.  The  engravings  thus  form  a  complete  and  splendid  series,  which  will 
greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recall- 
ing the  details  of  the  dissecting-room.  Combining,  as  it  does,  a  complete  Atlas  of 
Anatomy  with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy, 
the  work  will  be  found  of  great  service  to  all  physicians  who  receive  students  in  their 
offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the  groundwork  of  a 
thorough  medical  education. 

For  the  convenience  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost  necessi- 
tated by  the  use  of  colors,  the  volume  is  published  also  in  black  alone,  and  maintained 
in  this  style  at  the  price  of  former  editions,  notwithstanding  the  largely  increased  size  of 
the  work. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  ThuB 
bomplete,  the  work  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study. 

books.  The  work  is  published  with  black  and 
colored  plates.  It  is  a  marvel  of  book-making. — 
American  Praetitiontr  and  News,  Jan.  21, 1888. 

Gray's  Anatomy  is   the  most  magnificent  work 
upon  anatomy  whic^  has  ever  been  published  in 


The  most  popular  work  on  anatomy  ever  written. 
It  is  sufficient  to  say  of  it  that  this  edition,  thanks 
to  its  American  editor,  surpasses  all  other  edi- 
tions— .Tour,  uf  the  Amer.  Mel.  Ass'n,  Dec.  .31,  1887. 

A  work  which  for  more  than  twenty  years  has 


had  the  lead  of  all  other  text-books  on  anatomy  the  English  or  any  other  language.— Cinciiiuati 
throughout  the  civilized  world  comes  to  hand  in    Medical  News,  Nov.  1887. 

Buch  beauty  of  execution  and  accuracy  of  text  As  the  book  now  goes  to  the  purchaser  he  is  re- 
and  illustration  as  more  than  to  make  good  the  ceiving  the  best  work  on  anatomy  that  is  published 
large  promise  of  the  prospectus.  It  would  be  in-  in  any  language.— Kir<?inia  .Vtv/.  Monthly,  Dec.  1887. 
deed  difficult  to  name  a  feature  wherein  the  pres-  Gray's  standard  Anatomy  has  been  and  will  be 
ent  American  edition  of  Gray  could  be  mended  1  for  years  the  text-book  for  studentn.  The  book 
or  bettered,  and  it  needs  no  prophet  to  see  that  needs  only  to  be  examined  to  be  perfectly  under- 
the  royal  work  is  destined  for  many  years  to  come  »\.ood..— Medical  Press  of  Western  New  York,  Jan. 
to  hold   the  first  place  among  anatomical  text-  i  1888. 


Aljbo  fob  sale  separate — 
HOLUEN,  LUTHER,  F,  R,  C.  S., 

Sur<ieijn  to  SI.  Bartholotnew's  and  the  Foundling  Hospitals,  London. 

Landmarks.  Medical  and  Surgical.  Second  American  from  the  latest  reviaed 
English  edition,  with  additions  by  W.  \\.  Keen,  M.  D.,  Professor  of  Artistic  .Vnatomy  in 
the  Pennsylvania  Academy  of  the  Fine  AtIh,  formerly  Lecturer  on  .Xnatoniy  in  tlie  Phila- 
delphia S('h<K)l  of  Anatomy.     In  one  hands<jme  12mo.  volume  of  14«  pages.     Cloth,  $1.00. 

This  little  book  is  all  that  i-an  be  desired  within  |  cians  and  surgeons  is  much  to  be  encouraged.  It 
its  scope,  and  its  contents  will  be  found  simply  in-  i  inevitably  leads  to  a  progressive  <'.|ii.iilloii  nf  both 
Taluable  to  the  young  surgeon  f)r  physician,  since  I  theeye  and  the  touch,  by  which  !'•  :  Miof 

they  bring  before  him  such  data  a-  he  requires  at  ,  disease  or  the  lix-ali/.atinn  of  ini  \   a»- 

every  examination  of  a  patient.     It  is  written  In  '  sisted.   One  thoroughly  familiar  «  nere 

language  so  clear  and  concise  that  one  ought  taught  N  capable  of  a  degree  of  n.'.Mirii'V  and  a 
almost  to  learn  it  by  heart.  Ittear-hf-scliagnosis  by  confidonce  of  certainly  which  Is  othcrwi-..-  uiiat- 
external  examination,  ocular  and  palpable,  of  the  ;  tainable.  We  cor.iially  recomnic-nd  the  Landmark* 
body  with  such  anatomical  and  physiological  facts  to  the  attention  of  every  phyHJcian  who  has  not 
as  dircctlv  bear  on  the  subject,  ft  is  eminently  |  yet  provi.led  himself  with  a  copy  i>f  this  u«eful, 
thestudent'sandyoungprac!tltloner'sbook.—/Viv- I  practical  guide  to  the  correct  plaining  of  all  the 
sician  and  Surgeon,  Nov.  1881.  I  anatomical  parts  and  organs.— OirMidrt  M«die<U  and 

The  study  of  these  Landmarks  by  both  physl-  1  Surgical  Journal,  Dec.  1881. 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


ALLBN,  HARRISON,  M,  X>., 

Professor  oj  Physiology  in  the  University  of  Pemisylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  With  an  Intro- 
ductory Section  on  Histology.  By  E.  O.  Shakespeare,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section  I.  Histology. 
Section  II.  Bones  and  Joints.  Section  HI.  Muscles  and  Fascia.  Section  IV. 
Arteries,  Veins  and  Lymphatics.  Section  V.  Nervous  System.  Section  VI. 
Organs  of  Sense,  of  Digestion  and  Genito-Urinajiy  Organs,  Embryology, 
Development,  Teratology,  Superficial  Anatomy,  Post-Mortem  Examinations, 
AND  General  and  Clinical  Indexes.  Price  per  Section,  $3.50 ;  also  bound  in  one 
volume,  cloth,  $23.00 ;  very  handsome  half  Kussia,  raised  bands  and  open  back,  $25.00. 
For  sale  by  subscription  only.     Apply  to  the  Publishers. 


It  is  to  be  considered  a  study  of  applied  anatomy 
In  its  widest  sense — a  systematic  presentation  of 
sach  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgeiy.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  travelled  over  by  one  thoroughly  famil- 
iar with  it.    The  illustrations  are  made  witn  great 


care,  and  are  simply  superb.  There  is  as  much 
of  practical  application  of  anatomical  points  to 
the  every-day  wants  of  the  medical  clinician  as 
to  those  of  the  operating  surgeon.  In  fact,  few 
general  practitioners  will  read  the  work  without  a 
feeling  of  surprised  gratification  that  so  many 
points,  concerning  which  they  may  never  have 
thought  before  are  so  well  presented  for  their  con- 
sideration. It  is  a  work  which  is  destined  to  be 
the  best  of  its  kind  in  any  language. — Medical 
Record,  Nov.  25, 1882. 


CLARKE,W,B,,F,R,C,S.  &  LOCKWOODfC.B.,F,R,C,8. 

Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical  School,  London. 

The  Dissector's  Manual.     In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49  illustrations.     Limp  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  4. 
Messrs.ClarkeandLockwoodhave  written  a  book  I  intimate   association  with   students  could  have 


that  can  hardly  be  rivalled  as  a  practical  aid  to  the 
dissector.  Their  purpose, which  is  "how  to  de- 
scribe the  best  way  to  display  the  anatomical 
structure,"  has  been  fully  attained.  They  excel  in 
a  lucidity  of  demonstration  and  graphic  terseness 
of  expression,  which  only  a  long  training  and 


fiven.  With  such  a  guide  as  this,  accompanied 
y  so  attractive  a  commentary  as  Treves'  Surgical 
Applied  Anatomy  (same  series),  no  student  could 
fail  to  be  deeply  and  absorbingly  interested  in  the 
study  of  anatomy. — New  Orleans  Medical  and  Sur- 
gical Journal,  April,  1884. 


TREVES,  FREDERICK,  F.  R,  C.  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  HospitaL 
Surgical  Applied  Anatomy.     In  one  pocket-size  12mo.  volume  of  540  pages,, 
with  61   illustrations.   Limp  cloth,  red  edges,  $2.00.    See  Students^  Series  of  Manuals, 
page  4. 


He  has  produced  a  work  which  will  command  a 
larger  circle  of  readers  than  the  class  for  which  it 
was  written.  This  union  of  a  thorough,  practical 
acquaintance  with  these  fundamental  branches. 


This  number  of  the  "Manuals  for  Students"  is 
most  excellent,  giving  just  such  practical  knowl- 
edge as  will  be  required  for  application  in  relieving 
the  injuries   to  which  the  living  body  is  liable. 


quickened  by  daily  use  as  a  teacher  and  practi-  j  The  book  is  intended  mainly  for  students,  but  it 
tioner,  has  enabled  our  author  to  prepare  a  work  j  will  also  V)e  ofgreat  use  to  practitioners.  Theillus- 
which  it  would  be  a  most  difficult  task  to  excel.—  |  trations  are  well  executed  and  fully  elucidate  the 
The  American  Practitioner,  Feb.  1884.  |  text— Southern  Practitwri  er,  Feb.,  1884. 


BELLAMY,  EDWARD,  F,  R.  C.  S., 

Senior  Assistant-Surgeon  to  the  Charing-Cross  Hospital,  London. 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Regions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
operative  Surgery.    In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 

WILSON,  ERASMUS,  F,  R,  S. 

A  System  of  Human  Anatomy,  General  and  Special.  Edited  by  W.  H. 
GoBRECHT,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustrations. 
Qoth,  $4.00;  leather,  $5.00. 

CLELAND,  JOHN,  M.  D.,  F,  R.  S,, 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Onlwny. 

A  Directory  for  the  Dissection  of  the  Human  Body, 
volume  of  178  pages.     Cloth,  $1.25, 


In  one  12mo. 


HARTSHORNE'S  HANDBOOK  OF  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.    Cloth,  81.75.J 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  two  octavo  volumes  of  1007  r»i5e», 
with  320  woodcuts.    Cloth,  $6.00. 


Lea  Brothers  &  Co.'s  Publications — Physics,  Physiol.,  Anat.        7 
DMAI'EIt,  JOSN  C,  M.  J>.,  LL,  D., 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 
Medical  Physics.     A  Text-book  for  Students  and  Practitioners  of  Medicine.    In 
«eme  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.   Cloth,  $4. 

FROM  THE  PREFACE. 

The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admirable 
works  of  Desplats  and  Gariel,  of  Robertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  which  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  placing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  many  years  at  the 
University  of  the  City  of  New  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between  Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 

This  elegant  and  useful  work  bears  ample  testi-  I  explained,  acoustics,  optics,  heat,  electricity  and 
mony  to  the  learning  and  good  judgment  of  the  magnetism,  closing  with  a  section  on  electro- 
author.  He  has  fitted  his  work  admirably  to  the  '  biology.  Theapplicationsof  all  these  to  physiology 
exigencies  of  the  situation  by  presenting  the  |  and  medicine  are  kept  constantly  in  view.  The 
reader  with  brief,  clear  and  simple  statements  of  ;  text  is  amply  illustrated  and  the  many  difficult 
fluch  propositions  as  he  is  by  necessity  required  to  '  points  of  the  subject  are  brought  forward  with  re- 
master. The  subject  matter  is  well  arranged,  ruaikable  clearness  and  ability. — Medical  and  Surg- 
liberally  illustrated  and  carefully  indexed.    That    ical  Reporter,  July  18, 1885. 


It  will  take  rank  at  once  among  the  text-books  is 
certain,  and  it  is  to  be  hoped  that  it  will  find  a 
place  upon  the  shelf  of  the  practical  physician, 
where,  as  a  book  of  reference,  it  will  be  found 
useful  and  agreeable. — Louisville  Medical  News, 
September  26,  188.5. 

Certainly  we  have  no  textrbook  as  full  as  the  ex- 
cellent one  he  has  prepared.  It  begins  with  a 
statement  of  the  properties  of  matter  and  energy. 
After  these  the  special  departments  of  physics  are 


That  this  work  will  greatly  facilitate  the  study 
of  medical  physics  is  apparent  upon  even  a  mere 
cursory  examination.  It  is  marked  by  that  scien- 
tific accuracy  which  always  characterizes  Dr. 
Draper's  writings.  Its  peculiar  value  lies  in  the 
fact  that  it  is  written  from  the  standpoint  of  the 
medical  man.  Hence  much  is  omitted  that  ap- 
pears in  a  mere  treatise  on  physical  science,  while 
much  is  inserted  of  peculiar  value  to  the  physi- 
cian.— Medical  Record,  August  22, 1885. 


ROBERTSON,  J,  McGregor,  m,  a.,  m,  b., 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 
Physiological  Physics.     In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.    Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  4. 


The  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
aal  for  the  student  of  medicine,  an  auxiliary  to 
his  text-book  In  physiology,  and  it  wou  1  d  be  particu- 
larly useful  as  a  guide  to  his  laboratory  experi- 


ments. It  will  be  found  of  great  value  to  the 
practitioner.  It  is  a  carefully  prepared  book  of 
reference,  concise  and  accurate,  and  as  such  we 
heartily  recommend  it. — Journal  of  the  American 
Medical  Association,  Dec.  6, 1884. 


J) ALTON,  JOHJSr  a,  M-  !>., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.     Cloth,  $2. 

Dr.  Dalton's  work  is  the  fruit  of  the  deep  research  '  revolutionized  the  theories  of  teachers,  than  the 
of  a  cultured  mind,  and  to  the  busy  practitioner  it  |  discovery  of  the  circulation  of  the  blood.  This 
cannot  fail  to  be  a  source  of  instruction.  It  will  explains  the  extraordinary  Interest  it  has  to  all 
inspire  him  with  afeeling  of  gratitude  and  admir-  medical  historians.  The  volume  before  us  is  one 
ation  for  those  plodding  workers  of  olden  times,  of  three  or  four  which  have  been  written  within  a 
who  laid  the  foundation  of  the  magnificent  temple  few  years  by  American  physicians.  It  is  in  several 
of  medical  science  a.i  it  now  stands.— iVeiu  Orleans  respects  the  most  complete.  The  volume,  though 
Medical  and  Surgical  Journal,  Aug.  1885.  j  small  in  size,  is  one  of  the  most  creditable  con- 

In  the  progress  of  physiological  study  no  fact  tributlons  from  an  American  pen  to  medical  historv 
was  of  greater  moment,  none  more  completely  I  that  has  appeared.— Jlfed.  <t  Surg.  Rep.,  Dec.  6, 1884. 

BELL,  F,  JEFFREY,  M.  A,, 

Professor  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.  In  one  12mo.  volume  of  561  pages, 
with  229  illustrations.  Limp  cloth,  $2.00.     See  Students'  Serks  of  ManuaJs,  i)age  4. 

The  manual  is  preeminently  a  student's  book—  it  the  best  work  In  existonne  in  the  KnglUh 
clear  and  simple  in  language  and  arrangement,  language  to  place  in  the  hands  of  the  medical 
It  is  well  and  abundantly  illustrated,  and  is  read-  ,  Btudeni.— Bristol  Medico- Chirurgxeal  Journal,  Mar., 
«ble  and  interesting.    On  the  whole  we  consider  ,  1886. 

ELLIS,  GEORGE  VINER, 

Emenlus  Professor  of  Anntomv  in   University  CoUege,  London, 

Demonstrations  of  Anatomy.  Being  a  (Juide  to  the  Knowledge  of  the 
Human  BckIv  by  Dissection.  From  the  eighth  an(l  revised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  pages,  with  249  illustrations.    Cloth,  $4.2.');  l&itlier,  $5.26. 

ROBERTS,  JOHN  B.,  A,  M.,  M,  IK 

Prof  of  Appliol  Anal,  and  Ojier.  Surg,  in  Phila.  Polyclinic  anil  Coll.  for  Oraduates  in  Medietn*. 

The  Compend  of  Anatomy.  For  use  in  tlie  dissecting-room  and  in  preparing 
for  examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  76  cents. 


8        Lea  Brothers  &  Co.'s  Publications — Physiology,  Chemistry. 


CHAPMAN,  HENMT  C,  M,  Z>., 

Professor  of  Institutes  of  Medicine  and  Medical  Juris,  in  the  Jefferson  Med.  Coll.  of  Philadelphia. 

A  Treatise  on  Human  Physiology.      Jn  one  handsome  octavo  volume  of 
925  pages,  with  605  fine  engravings.     Cloth,  $5.50  ;  leather,  $6.50. 

farther,  and  the  latter  will  find  entertainment  and 
instruction  in  an  admirable  book  of  reference. — 
North  Carolina  Medical  Journal,  Nov.  1887. 


It  represents  very  fully  the  existing  state  of 
physiology.  The  present  work  has  a  special  value 
to  the  student  and  practitioner  as  devoted  more 
to  the  practical  application  of  well-known  truths 
which  the  advance  of  science  has  given  to  the 
profession  in  this  department,  which  may  be  con- 
sidered the  foundation  of  rational  medicine. — Btif- 
falo  Medical  and  Surgical  Journal,  Dec.  1887. 

Matters  which  have  a  practical  bearing  on  the 
practice  of  medicine  are  lucidly  expressed;  tech- 
nical matters  are  given  in  minute  detail;  elabo- 
rate directions  are  stated  for  the  guidance  of  stu- 
dents in  the  laboratory.  In  every  respect  the 
work  fulfils  its  promise,  whether  as  a  complete 
treatise  for  the  student  or  for  the  physician  ;  for 
the  former  it  is  so  complete  that  he  need  look  no 


The  work  certainly  commends  itself  to  both 
student  and  practitioner.  What  is  most  demanded 
by  the  progressive  physician  of  to-day  is  an  adap- 
tation of  physiology  to  practical  therapeutics,  and 
this  work  is  a  decided  improvement  in  this  respect 
over  other  works  in  the  market.  It  will  certainly 
take  place  among  the  most  valuable  text-books. — 
Medical  Age,  Nov.  25,  1887. 

It  is  the  production  of  an  author  delighted  with 
his  work,  and  able  to  inspire  students  with  an  en. 
thusiasm  akin  to  his  own. — American  Practitioner 
and  News,  Nov.  12, 1887. 


DALTONf  JOHN  C,  M,  J>., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New   York,  etc. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewritten.  In  one 
very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00 ;  leather,   $6.00 ;  very  handsome  half  Russia,  raised  bands,  $6.50. 

have  never  been  in  any  doubt  as  to  its  sterling 
worth.— iV.  }'.  Medical  Journal,  Oct.  1882. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 
which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — Dublin  Journal  of  Medical  Science,  Feb.'83. 


From  the  first  appearance  of  the  book  it  has 
been  a  favorite,  owing  as  well  to  the  author's 
renown  as  an  oral  teacher  as  to  the  charm  of 
simplicity  with  which,  as  a  writer,  he  always 
succeeds  In  investing  even  intricate  subjects. 
It  must  be  gratifying  to  him  to  observe  the  fre- 
quency with  which  his  work,  written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  lact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  the  thou- 
sands who  have  studied  it  in  its  various  editions 


FOSTER,  MICHAEL,  M.  D.,  F.  B.  S,, 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.     New  (fourth)  American  from  the  fifth  and  revised 
English  edition,  with  notes  and  additions  by  E.  T.  Reichert,  M.  D.,  Prof,  of  Phvsi- 
ology  in  Univ.  of  Penna.     Preparing. 

A  REVIEW   OF    THE  FIFTH  ENGLISH   EDITION   IS  APPENDED. 


It  is  delightful  to  meet  a  book  which  deserves 
only  unqualified  praise.  Such  a  book  is  now  before 
us.  It  is  in  all  respects  an  ideal  text-book.  With  a 
complete,  accurate  and  detailed  knowledge  of  his 
subject,  the  author  has  succeeded  in  giving  a 
thoroughly  consecutive  and  philosophic  account 
of  the  science.  A  student's  attention  is  kept 
throughout  fixed  on  the  great  and  salient  ques- 


tions, and  his  energies  are  not  frittered  away  and 
degenerated  on  petty  and  trivial  details.  Review- 
ing this*voIume  as  a  whole  we  are  justified  in  say- 
ing that  it  is  the  only  thoroughly  good  text-book 
of  physiology  in  the  "English  language,  and  that  it 
is  proV)ably  the  best  text-book  in  ANY  language. 
—Edinburgh  Medical  Journal,  December  1888. 


POWER,  HENRY,  M.  B,,  F.  B.  C,  S., 

Examiner  iii  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.     Second  edition.     In  one  handsome  pocket-size  12mo.  vol- 
ume of  396  pp.,  with  47  illustrations.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  p.  4. 

SIMON,  W,,  Ph.  D.,  M.  2>., 

Professor  of  Chemistry  and  Toxicology  in  the   College  of  Physicians  and  Surgeons,  Baltimore,  cmd 
Professor  of  Chemistry  in  the  Maryland  College  of  Pharmacy. 

Manual  of  Chemisti^r.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
New  (second)  edition .  In  one  8vo.  vol.  of  478  pp.,  with  44  woodcuts  and  7  colored  plates 
illustrating  56  of  the  most  important  chemical  tests.     Just  ready.     Cloth,  $3.25. 

FROM  THE  PREFACE. 
It  has  been  the  aim  of  the  Author  to  present  a  work  on  general  chemistry  which  may  be  used  to 
advantage  as  a  text-book  by  beginners,  and  which,  at  the  same  time,  covers  the  special  needs  of  the 
medical  and  pharmaceutical  student.  While  the  general  ehftracter  of  the  second  edition  is  the  same 
as  that  of  the  first,  many  changes  and  numerous  additions  have  been  made  with  the  view  of  render- 
ing the  work  more  complete  and  useful.  For  the  special  benefit  of  pharmaceutical  and  medical  stu- 
dents all  chemicals  mentioned  in  the  United  States  Pharmacopceiaare  included,  and  when  of  suflScient 
interest,  are  fully  considered.  Having  frequently  noticed  the  difficulty  experienced  by  beginners  in 
becoming  familiar  with  the  variously  shaded  colors  of  chemicals  and  their  reactions,  the  Author 
decided  to  illustrate  the  work  with  a  number  of  plates,  presenting  the  colors  of  those  most  important. 

Wohler's  Outlines  of  Organic  Chemistry.  Edited  by  Fittig.  Translated 
by  Ira  Remsen,  M.  D.,  Ph.  D.     In  one  12mo.  volume  of  550  pages.     Cloth,  $3. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
Abuse  of  Alcoholic  Liquors  in  Health  and  Dis- 
ease. With  explanationsof  scientific  words.  Small 
12mo.    178  pages.    Cloth,  60  cents. 
GALLOWAY'S  QUALITATIVE  ANALYSIS. 


LEHMANN'S  MANUAL  OF  CHEMICAL  PHYS- 
IOLOGY. In  one  octavo  volume  of  327  pages, 
with  41  illustrations.    Cloth,  $2.26. 

CARPENTER'S  HUMAN  PHYSIOLOGY.  Edited 
by  Henbt  Powf.b.    In  one  octavo  volume. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


FRANKLANn,  E.,  D.  C.  i.,  F.It.S,,  &JAFP,  F,  JR.,  F.  I.  C, 


Professor  of  Chemistry  in  the  Normal  School 
of  Science,  London. 


Assist.  Prof,  of  Chemistry  in  the  Normal 
School  of  Science,  London. 


Inorganic  Chemistry.     In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 


This  work  should  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certainly  better 
adapted  than  any  work  upon  chemistry, with  which 
we  are  acquainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med 


This  excellent  treatise  will  not  fail  to  take  ita 
place  as  one  of  the  very  best  on  the  subject  of 
which  it  treats.  We  have  been  much  pletised 
with  the  comprehensive  and  lucid  manner  in 
which  the  difficulties  of  chemical  notation  and 


Icine  should  have.  Physicians  who  feel  that  their  |  nomenclature  have  been  cleared  up  by  the  writers, 
chemical  knowledge  is  behind  the  times,  would  I  It  shows  on  every  page  that  the  problem  of 
do  well  to  devote  some  of  their  leisure  time  to  the  [  rendering  the  obscurities  of  this  science  easy 
study  of  this  work.  The  descriptions  and  demon- '  of  comprehension  has  long  and  successfully 
strations  are  made  so  plain  that  there  is  no  diffi-  ]  engaged  the  attention  of  the  authors. — Medical 
culty  in  understanding  them. — Cincinnati  Medical  j  and  Surgical  Reporter,  October  31,  1885. 
News,  January,  1886.  | 

FOWJ^FS,  GFORGE,  Ph,  D, 

A   Manual  of  Elementary    Chemistry;     Theoretical  and  Practical.     Em- 
bodying Watts'  Physical  Inorganic  Chemistry.     New  American,  from  tiie  twelfth  English 
edition.     In  one  large  royal  12mo.  volume  of  1061  pages,  with   168  illustrations  on  wood 
and  a  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 
Fownes'   Chemistry  has    been   a  standard  text-  [  chemistry  extant. — Cincinnati  Medical  News,  Oc- 


tober, 1885. 

Of  all  the  works  on  chemistry  intended  for  the 
use  of  medical  students,  Fownes'  Chemistry  is 
perhaps  the  most  widely  used.  Its  popularity  is 
oased  upon  its  excellence.    This  last  edition  con- 


t)ook  upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
eyerywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 

discoveries,  the  work  has  been   revised  so  as  to  _       

keep  it  abreast  of  the  times.  It  has  steadily  tains  all  of  the  material  found  in  the  previous, 
maintained  its  position  as  a  text-book  with  medi-  and  it  is  also  enriched  by  the  addition  of  Watts' 
cal  students.  In  this  work  are  treated  fully :  Heat,  Physical  and  Lwrqanic  Chemistry.  All  of  the  mat- 
Light  and  Electricity,  including  Magnetism.  The  ter  is  brought  to  the  present  standpoint  of  chemi- 
innuence  exerted  by  these  forces  in  chemical  cal  knowledge.  We  may  safely  predict  for  this 
action  upon  health  and  disease,  etc.,  is  of  the  most  work  a  continuance  of  the  fame  and  favor  it  enioys 
important  kind,  and  should  be  familiar  to  every  among  medical  students. — New  Orleans  Medical 
medical  practitioner.  We  can  commend  the  and  SurgicalJournal,  M&Tah,  1SS6. 
work  as  one  of  the    very  best  text-books    upon  | 

ATTFIEZD,  JOHN,  Fh.  !>., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Oreat  Britain,  etc 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopceia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  twelfth 
English  edition,  specially  revised  by  the  Author  for  America.  In  one  handsome  royal 
12mo.  volume  of  about  750  pages,  with  about  100  illustrations.     In  press. 

A  notice  of  the  previous  edition  is  appended. 


It  is  a  book  on  which  too  much  praise  cannot  be 
bestowed.  As  a  text-book  for  medical  schools  it 
is  unsurpassable  in  the  present  state  of  chemical 
science,  and  having  been  prepared  with  a  special 
view  towards  medicine  and  pharmacy,  it  is  alike 
Indispensable  to  all  persons  engaged  in  those  de- 
partments of  science.  It  includes  the  whole 
chemistry  of  thelast  Pharmacopoeia. — Pacific  Medi- 
cal and  Surgical  .Journal,  Jan.  1884. 

A  text^book  which  passes  through  ten  editions 


in  sixteen  years  must  have  good  qualities.  It 
seems  desirable  to  point  out  that  feature  of  the 
book  which,  in  all  probability,  has  made  it  so 
popular.  There  can  be  little  doubt  that  it  is  its 
thoroughly  practical  character,  the  expression 
being  used  in  its  best  sense.  Tne  author  under- 
stands what  the  student  ought  to  learn,  and  is  able 
to  put  himself  in  the  student's  place  and  to  appre- 
ciate his  state  of  mind. — American  Chemical  Jour- 
nal,  .KprU,  1884. 


BLOXAM,  CHARLES  i., 

Professor  of  Chemistry  in  King's  College,  London. 

Chemistry,  Inorganic  and  Organic.  New  American  from  the  fifth  Lon- 
don edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2.00  ;  leather,  $3.00. 


Comment  from  us  on  this  standard  work  is  al- 
most superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypotheses  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 
quence that  the  student  never  has  occanion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  to  experimental  illustrations  ol 
chemical  principles  and  phenomena,  and  the 
mode  of  con.lucting  these  experim.'nts.  The  book  | 
maintains  the  position  it  ha-*  always  held  as  one  of  | 


the  best  manuals  of  general  chemistry  In  the  Engf- 
lish  language.— />efroi7  Ixinf.et,  F»>b.  1«84. 

We  know  of  no  treatise  on  chemistry  which 
contains  so  much  practical  information  In  the 
same  number  of  pages.  The  book  can  be  readily 
adapted  not  only  to  the  needs  of  those  who  desire 
a  tolerably  complete  course  of  clipmistry,  but  aloo 
to  the  needs  of  those  who  ileslre  only  n  general 
knowledge  of  the  subject.  Wo  lake  pleasure  In 
recommending  tliis  work  both  as  a  satisfactory 
text- book,  and  as  ii  useful  book  of  reference.— floa- 
ton  Metiirnl  aiul  Sun/iral  Journal,  June  19,  1884. 


GREENE,  WILLIAM  H.,  M.  !>., 

Dcvionxlrator  of  Chemi.ftry  in  the  Midical  Department  of  the  Univentity  of  Pennsylvania. 
A  Manual  of  Medical  Chemistry.    For  tlie  use  of  Students.     BnHe<l  uiK)n  Bow. 
man's  xMedic^il  Chemistry.    In  one  12iuo.  volume  of  310  pages,  witli  74  iUua.    Cloth,  $1.75. 
It  is  a  concise  manual  of  three  hutMlr.-l  iiiK-s,  1  the  recognition  of  oomr-^undsdue  to  pathologlc»l 
giving  an  excellent  summary  of  th.-  '  •  <■<     conilltlons.      'I  he  detwtion  of  polnouH  Ih  IroaUwl 

of  analyzing  the  liquids  and  solids  of ' 
for  the'estimation  of  their  normal  cm 


conilltions. 

with  Hurtlcicnt  fulneas  for  the  purtKme  of  tb«Htu- 

dentor  prwtltloner.- flo»^<n  Jl.  of  Chrm.  June,'80. 


10 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


RBMSBN,  IMA,  M,  D.,  Ph,  2>., 

Professor  of  Chemistry  in  the  Johns  Hopkins  Univmsity,  Baltimore. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.  New  (third)  and  thoroughly  revised  edition.  In  one  hand- 
some royal  12mo.  volume  of  316   pages.     Cloth,  $2.00.     Just  ready. 

This  work  of  Dr.  Remsen  is  the  very  textrbook  !  examination  of  college  faculties  as  f.Ae  text-book  of 
needed,  and  the  medical  student  who  has  it  at  ,  chemical  instruction.— Si.  Louis  Medical  and  Sur- 
his  fingers'  ends,  so  to  speak,  can,  if  he  chooses,  ;  gical  Journal,  January,  1888. 

make  himself  familiar  with  any  branch  of  chem-  j  It  is  a  healthful  sign  when  we  see  a  demand  for 
istry  which  he  may  desire  to  pursue.  It  would  be  j  a  third  edition  of  such  a  book  as  this.  This  edi- 
difficult  indeed  to  find  a  more  lucid,  full,  and  at  i  tion  is  larger  than  the  last  by  about  seventy-five 
the  same  time  compact  explication  of  the  philos-  pages,  and  much  of  it  has  been  rewritten,  thus 
ophy  of  chemistry,  than  the  book  before  us,  and  i  bringing  it  fully  abreast  of  the  latest  investiga- 
we  recommend  it  to  the  careful  and  impartial  |  tions.— A'.  Y.  Medical  Journal,  Dec.  31, 1887. 

CHARLES,  T.  CBANSTOVN,  M.  2)7,  F,  C,  S.,  M.  S,, 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen's  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.     A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  with  38  woodcuts  and  1  colored  plate.  Cloth,  $3.50. 
Dr.  Charles  is  fully  impressed  with  the  import-    nowadays.    Dr.  Charles  has  devot«d  much  space 


tffice  and  practical  reach  of  his  subject,  and  he 
has  treated  it  in  a  competent  and  instructive  man- 
ner. We  cannot  recommend  a  better  book  than 
the  present.  In  fact,  it  fills  a  gap  in  medical  text- 
books, and  that  is  a  thing  which  can  rarely  be  said 


to  the  elucidation  of  urinary  mysteries.  He  does 
this  with  much  detail,  and  yet  in  a  practical  and 
intelligible  manner.  In  fact,  the  author  has  filled 
his  book  with  many  practical  hints.— Jlfedicoi  Rec- 
ord, December  20,  1884. 


HOFFMAJSIS^,  F,,  A.M„  Ph,I).,  &  FOWFB  FB.,  Ph.D., 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chem.  iri  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 


We  congratulate  the  author  on  the  appearance 
of  the  third  edition  of  this  work,  published  for  the 
first  time  in  this  country  also.  It  is  admirable  and 
the  information  it  undertakes  to  supply  is  both 
extensive  and  trustworthy.  The  selection  of  pro- 
cesses for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  the  descrip- 


tion of  them  singularly  explicit.  Moreover,  It  is 
exceptionally  free  from  typographical  errors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pharmor- 
ceutical  Journal  and  TVansactions,  1883. 


CLOWES,  FMAJVE:,  n.  Sc,  London, 

Senior  Science- Master  at  the  High  School,  Newcastle-under-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  387  pages,  with  55  illustrations.  Cloth, 
$2.50. 

This  work  has  long  been  a  favorite  with  labora-  student  in  the  performance  of  each  analysis, 
tory  instructors  on  account  of  its  systematic  plan.  These  characteristics  are  preserved  in  the  present 
carrying  the  studentstep  by  step  from  the  simplest  edition,  which  wecan  heartily  recommend  as  asat- 
auestions  of  chemical  analysis,  to  the  more  recon-  isfactory  guide  for  the  student  of  inorganic  chem- 
aite  problems.  Features  quite  as  commendable  ical  analysis. — New  York  Medical  Journal,  Oct.  9, 
are  the  regularity  and  system  demanded  of  the    1886. 


BALFE,  CMABLES  JS,,  M.  n.,  F.  B,  C.  P., 

Assistant  Physician  at  the  London  Hospital. 

Clinical  Chemistry.     In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 
illustrations.     Limp  cloth,  red  edges,  $1.50 


This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the  book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ought  to 
know,  of  the  applications  of  chemistry  in  medi- 


See  Students''  Series  of  Manuals,  page  4. 
cine.  Dr.  Ralfe  is  thoroughly  acquainted  with  the 
latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  harmony  with  the 
modern  scientific  methods  and  spirit. — Medical 
Record,  February  2, 1884. 


CLASSEN,  ALEXANnEB, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 
Elementary  Quantitative  Analysis.     Translated,  with  notes  and  additions,  by 
Edgar  F.  Smith.  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.     In  one  12mo.  volume  of  324  pages,  with  36  illust.     Cloth,  $2.00. 

It  is  probably  the  best  manual  of  an  elementary  and  then  advancing  to  the  analysis  of  ininerals  and 
iMtture  extant,  insomuch  as  its  methods  are  the  such  products  as  are  met  with  in  applied  chemis- 
best  It  teaches  by  examples,  commencing  with  try.  It  is  an  indispensable  book  for  students  in 
single    determinations,   followed  by  separations,    chemistry. — Boston  Jowrnal  of  Chemistry,  Oct.  1878. 


Lea  Brothers  &  Co.'s  Publications — Pharm.,  Mat.  Med.,  Therap.  11 
BBVNTOX,  T.  LAUDJEB,  iHf.D.,  n,Sc.,  F.B.S.,  F.B.ai*,, 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomeic's  Hospital,  London,  etc. 

A  Text-book  of  Pharmacology,  Therapeutics  and  Materia  Medica ; 

Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
New  (3d)  edition.  Octavo,  1305  pages,  230  illuetrations.  Cloth,  $5.50 ;  leather,  $6.50. 
The  present  edition  has  the  same  merits  of  ful-  j  truth.  The  great  merit  of  this  work  :s  that  tho 
ness  and  clearness  which  its  predecessors  pos-  I  author  has  been  able  so  well  to  coordinate  facts 
8essed.  It  has  been  revised  so  as  to  devote  more  I  into  an  intelligible  and  rational  system  of  pharraa- 
attention  to  certain  matters  which  have  undergone  oology,  and  henceforth  no  treatise  on  therapeutics 
rapid  development  within  tlie  last  few  years.  It  will  be  considered  complete  which  does  not  in 
presents  a  very  accurate  view  of  the  present  state  some  measure  adopt  this  method.  The  busy 
of  knowledge  in  regard  to  its  subject.    A  noticeable    physician  will  approach  this  book  to  learn  some- 


feature  of  this  book  is  its  very  complete  index  of 
remedies,  and  a  iielpful  index  of  diseases  and  the 
medicaments  which  may  be  used  in  treating  them. 
— Medical  and  Surgical  Reporter,  Nov.  17,  1888. 

Nothing  so  original  and  so  complete  on  the  action 
of  drugs  on  the  body  generally  and  on  its  various 
parts,  has  appeared  during  the  life  of  the  present 
generation.    This  is  strong  language,  but  it  is  the 


thing  that  will  better  fit  him  for  his  work,  and  on 
every  page  he  will  find  something  that  will  reward 
him'for  the  time  spent  in  its  perusal.  We  com- 
mend this  book  as  one  which  every  physician 
should  own  and  study.  It  is  a  work  which  if  once 
owned  will  be  likely  to  be  read  and  consulted  till 
the  covers  fall  off  from  much  use. — Boston  Mtdical 
and  Surgical  Journal,  Dec.  20, 1888. 


MAISCH,  JOHNM,,  Plmr.  J>., 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  PJiysicians.  New  (3d)  edition,  thoroughly  revised.  In  one  handsome  royal  12mo. 
volume  of  523  pages,  with  257  illustrations.     Cloth,  $3. 

Prof.  Maisch  is  one  of  the  most  distinguished  sicians,  containing  the  most  recent  and  reliable 
pharmacists  of  this  country.  He  and  Prof.  Stillfi  information  in  regard  to  drugs.— Cincin?iati  Medi- 
are    the    authors  of    The    National    Dispensatory,    cat  News,  Nov.  1887. 

which  is  not  excelled  by  any  work  of  its  Kind  ever  We  do  not  know  of  any  work  in  the  English  Ian- 
published.  The  learning  and  experience  of  the  j  guage  which  covers  the  ground  so  well,  and  hence 
author,  therefore,  is  a  guarantee  that  his  manual  its  popularity  is  deserved.  Prof.  Maisch  is  one  of 
is  well  adapted  for  its  purpose,  viz. :  a  text-  and  i  the  acknowledged  pharmaceutical  educators  of 
reference-book  for  students,  pharmacists  and  phy-  I  this  country .-^«ter.  Practitioner  <fc  News,  Aug.  18,'88. 

BABTHOLOW,  ROBERTS,  A,  M.,  M.  !>.,  LL.  X>., 

Professor  of  Materia  Medica  and  General   Therapeutics  in  the  Jefferson  Med.  Coll.  of  Philadelphia. 

New  Remedies  of  Indigenous  Sourco:  Their  Physiological  Actions  and 
Therapeutical  Uses.     In  one  octavo  volume  of  about  300  pages.     Preparing. 

P ARRIS H,  EnwARn, 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 
A  Treatise  on  Pharmacy :    designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and   Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegajjd,  Ph.  G.      In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.     Cloth,  $5 ;  leather,  $6. 


There  is  nothing  to  equal  Parrish's  Pharmacy 
in  this  or  any  other  language. — London  Pharma- 
ceutical Journal. 

No  thorough-going  pharmacist  will  fail  to  possess 
himself  of  so  useful  a  guide  to  practice,  and  no 
physician  who  properly  estimates  the  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most  effective  meth- 
ods of  combination  are  concerned,  can  afford  to 
leave  this  work  out  of  the  list  of  their  works  of 


reference.  The  country  practitioner,  who  must 
always  be  in  a  measure  his  own  pharmacist,  will 
find  it  indispensable. — Louisville  Medical  News, 
March  29,  1884. 

All  that  relates  to  practical  pharmacy — apparatus. 
proce.sses  and  dispensing — has  been  arranged  ana 
described  with  clearness  In  its  various  asuect.-*,  so 
as  to  afford  aid  and  advice  alike  to  the  student  and 
to  the  practical  pharmacist.  The  work  is  judi- 
ciously illustrated  with  good  woodcuts — American 
Journal  of  Pharmacy,  January,  1884. 


HERMAJn^f  Dr.  i., 

Professor  of  Physiology  in  the  University  of  Zurteh. 
Experimental  Pharmacology.     A  Handbook  of  Methinls  for  Determining  the 
Physiological  Actions  of  Drugs.     Translated,  with   the  Author's  permi-ssion,  and   with 
extensive  additions,  by  Robert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.      12mo.,  199    pages,  with  32  illustrations,     ('loth,  $1.50. 

BRUCE,  J.  MITCHELL,  M.  D,,  F,  R.  C,  P., 

Physician  and  Lecturer  on  Materia  Medica  awl  Therapeutics  at  Charing  Cross  Hospital,  London. 
Materia  Medica  and  Therapeutics.     An  IntnHluction  to  Rational  Treatment. 
Fourth  edition.     12mo.,  591  pages.     Cloth,  $1.50.     See  Stvdmts'  Sei-Us  of  MmiuaU,  page  4. 

STILLE,  ALFRED,  M,  !>.,  LL.  !>., 

Professor  of  Theory  and  Practice  of  Med.  and  of  Cliniral  Med.  in  the  Univ.  of  Pinna. 

Therapeutics  and  Materia  Medica.  A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  including  their  Description  and  HiHU)ry.  Fourth  e«Ution, 
revised  and  enlarged.  In  two  large  and  hamisome  octavo  volumes,  containing  1936  pagei. 
Cloth,  $10.00;  leather,  $12.00;  very  handsome  half  Russia,  raised  bands,  $13.00. 

GRIFFITH,  ROBERTJEGLESFTELIh  M.  D. 

A  Universal  Formulary,  containing  the  Methods  of  Preimring  and  .Vdiniuifl- 
tering  Officinal  and  olla-r  Mt-diciiics.  The  whole  adapted  to  PliVHiclans  mid  I'hariiiaceut- 
bts.  Third  edition,  liiuroiiglily  revised,  with  numerous  a<lditi()nH,  by  John  M.  Maihoh, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Phihulelphia  College  of  Pharmacy, 
in  ont>  octavo  vrjb-mp  .>f  775  p!«?e«.  with  3H  illustrations.     Cloth,  $4.50;  leather,  $5.50. 


12        Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therap. 


8TILLB,  A,,  M.n,,LL.n,,  &  MAISCM,  J,  M,,Phar.D,, 


Professor  Evieritus  of  the  Theory  and  Prac- 
tice of  Medicine  arid  of  Clinical  Medicine 
in  the  Universitp  of  Pennsylvania. 


Prof,  of  Mat.  Med.  and  Botany  in  Phila. 
College  of  Pharmacy,  Sec' p  to  the  Ameri- 
can Pharmaceutical  Association. 


The  National  Dispensatory. 

CONTAINING  THE  NATURAL  HISTORY.  CHEMISTRY.  PHARMACY,  ACTIONS  AND    USES   OF 

MEDICINES,  INCLUDING  THOSE  RECOGNIZED  IN  THE  PHARMACOPCEIAS  OF  THE 

UNITED  STATES.  GREAT  BRITAIN  AND  GERMANY,  WITH  NUMEROUS 

REFERENCES    TO  THE  FRENCH  CODEX. 

Fourth  edition  revised,  and  covering  the  new  British  Pharmacopoeia.  In  one  mag- 
nificent imperial  octavo  vohime  of  1794  pages,  with  311  elaborate  engravings.  Price 
in  cloth,  $7.25;  leather,  raised  bands,  $8.00;  very  handsome  half  Russia,  raised  bands 
and  open  back,  $9.00.  *^*  This  work  tnll  be  furnished  with  Patent  Ready  Reference  Thumb- 
letter  Index  for  $1.00  in  addition  to  the  price  in  any  style  of  binding. 

In  this  new  edition  of  The  National  Dispensatoky,  all  important  changes  in  the 
recent  British  Pharmacopceia  have  been  incorporated  throughout  the  volume,  while  in 
the  Addenda  will  be  found,  grouped  in  a  convenient  section  of  24  pages,  all  therapeutical 
novelties  which  have  been  established  in  professional  favor  since  the  publication  of  the 
third  edition  two  years  ago.  Since  its  first  publication.  The  National  Dispensatory 
has  been  the  most  accurate  work  of  its  kind,  and  in  this  edition,  as  always  before,  it  may 
be  said  to  be  the  representative  of  the  most  recent  state  of  American,  English,  German 
and  French  Pharmacology,  Therapeutics  and  Materia  Medica. 
It  is  with  much  pleasure  that  the  fourth  edition  1  discovery  have  received  due   attention. — Kansas 


of  this  magnificent  work  is  received.  The  authors 
and  publishers  have  reason  to  feel  proud  of  this, 
the  most  comprehensive,  elaborate  and  accurate 
work  of  the  kind  ever  printed  in  this  country.  It 
is  no  wonder  that  it  has  become  the  standard  au- 
thority for  both  the  medical  and  pharmaceutical 
profession,  and  that  four  editions  have  been  re- 
quired to  supply  the  constant  and  increasing 
demand  since  its  first  appearance  in  1879.  The 
entire  field  has  been  gone  over  and  the  various 
articles  revised  in  accordance  with  the  latest 
developments  regarding  the  attributes  and  thera- 
peutical action  of  drugs.    The  remedies  of  recent 


City  Menical  Index,  Nov.  1887. 

We  think  it  a  matter  for  congratulation  that  the 
profession  of  medicine  and  that  of  pharmacy  have 
shown  such  appreciation  of  this  great  work  as  to  call 
for  four  editions  within  the  comparatively  briel 
period  of  eight  years.  The  matters  with  which  it 
deals  are  of  so  practical  a  nature  that  neither  the 
physician  nor  the  pharmacist  can  do  without  the 
latest  text- books  on  them,especially  those  that  are 
so  accurate  and  comprehensive  as  this  one.  The 
book  is  in  every  way  creditable  both  to  the  authors 
and  to  the  publishers. — Neva  York  Medical  Jowmal, 
May  21, 1887. 


JBAItQVHABSON,  ROBERT,  M.  D.,  F,  R,  C,  P,,  LL,  D., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School,  London. 

A  Guide  to  Therapeutics  and  Materia  Medica.  New  (fourth)  American, 
from  the  fourth  English  edition.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia.  By 
Frank  Woodbury,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  and  Clinical 
Medicine  in  the  Medico-Chirurgical  College  of  Philadelphia.  In  one  handsome  12mo. 
volume  of  581  pages.     Cloth,  $2.50.     Just  ready. 

FROM  THE  AMERICAN  EDITOR'S  PREFACE  TO  THE  FOURTH  EDITION. 
Although  the  fourth  English  edition  of  this  work  was  practically  rewritten  and  con- 
siderably enlarged,  so  rapid  has  been  the  advance  in  therapeutics  and  so  great  the  additions 
to  our  materia  medica  that  the  American  editor  has  found  it  necessary  to  make  very  many 
additions  so  as  to  make  the  body  of  the  work  include  all  remedies  and  preparations  of  the 
last  revision  of  the  U.  S.  Pharmacopoeia ;  a  number  of  non-officinal  but  important  new  drugs 
are  also  considered,  thus  making  the  work  as  complete  in  the  department  of  materia  medica 
as  it  is  in  therapeutics.  In  view  of  the  recent  publication  of  tlie  Formulary  of  the  Ameri- 
can Pharmaceutical  Association,  containing  many  valuable  formulae  that  physicians  should 
be  familiar  with,  it  has  been  deemed  advisable  to  add  this,  although  it  has  increased  the 
size  of  the  book  by  nearly  sixty  pages.  New  prescriptions  have  also  been  added.  In  its 
present  form  it  is  believed  that  it  will  continue  to  serve  a  useful  purpose  as  a  handy  ref- 
erence book  on  therapeutics  and  materia  medica  for  the  busy  practitioner  as  well  as  for  the 
medical  student. 

JEJDBS,  ROBERT  T.,  M.  D., 

Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Department. 

A  Text-Book  of  Therapeutics  and  Materia  Medica.  Intended  for  the 
Use  of  Students  and  Practitioners.     Octavo,  644  pages.     Cloth,  $3.50 ;  leather,  $4.50. 


The  treatise  will  be  found  to  be  concise  and 
practical,  bringing  the  subject  down  to  the  latest 
developments  cf  therapeutics  and  pharmacology. 
The  student  and  practitioner  will  find  the  book  a 
valuable  one  for  reference  and  study,  the  former 
being  facilitated  by  a  full  and  excellent  index. — 
St.  Louis  Medical  and  Surgical  .Journal,  Jan.  1888. 

The  present  work  seems  destined  to  take  a  prom- 
inent place  as  a  text-book  on  the  subjects  of  which 
it  treats.  It  possesses  all  the  essentials  which  we 
expect  in  a  book  of  its  kind,  such  as  conciseness, 
clearness,  a  judicious  cla.«sification,  and  a  reason- 
able degree  of  dogmatism.  The  style  deserves 
the  highest  commendation  for  its  dignity  and 
purity  of  diction.  The  student  and  young  practi- 
tioner need  a  safe  guide  in  this  branch  of  medi- 


cine. Such  they  can  find  in  the  present  author. 
All  the  newest  drugs  of  promise  are  treated  of. 
The  clinical  index  at  the  end  will  be  found  very 
useful.  We  heartily  commend  the  book  and  con- 
gratulate the  author  on  having  produced  so  good 
a  one.— iV.  }'.  Medical  Joui  nal,  Feb.  18,  1888. 

Dr.  Edes'  book  represents  better  than  any  older 
book  the  practical  therapeutics  of  the  present 
day.  The  book  is  a  thoroughly  practical  one.  The 
classification  of  remedies  has  reference  to  their 
therapeutic  action,  and  such  a  classification  will 
always  meet  the  approval  of  the  student.  The  rela- 
tive importance  of  different  remedies  is  indicated 
by  the  space  devoted  to  each,  and  by  the  use  of 
larger  type  in  the  titles  of  the  more  important 
articles. — Pharmaceutical  Era,  Jan.  1888. 


Lea  Brothers  &  Co.'s  Publications — Pathol.,  Histol.  13 

JPATNE,  JOSEPH  F.,  M.  D.,  F.  B,  C.  P., 

Member  of  the  Pathological  Society,  Senior  Assistant  Physician  and  Lecturer  on  Pathological  Anat- 
omy, St.  Thomas'  Hospital,  London. 

A  Manual  of  Generial  Pathology.  Designed  as  an  Introduction  to  the  Prac- 
tice of  Medicine.  Octavo  of  524  pages,  with  152  illus.  and  a  colored  plate.  Cloth,  $3.50. 
Knowing,  as  a  teacher  and  examiner,  the  exact  cal  factors  in  those  diseases  now  with  reasonable 
needs  of  medical  students,  the  author  has  in  the  certainty  ascribed  to  pathogenetic  microbes.  In 
work  before  us  prepared  for  their  especial  use  this  department  he  has  been  very  full  and  explicit, 
what  we  do  not  hesitate  toieay  is  the  best  introduc-  not  only  in  a  descriptive  manner,  but  in  the  tech- 
tion  to  general  pathology  that  we  have  yet  ex-  nique  of  investigation.  The  .Appendix,  giving 
amined.  A  departure  which  our  author  has  ;  methods  of  research,  is  alone  worth  tne  price  of  the 
taken  is  the  greater  attention  paid  to  the  causa-  book,  several  times  over,  to  every  student  of 
tion  of  disease,  and  more  especially  to  the  etiologi-    pathology. — St.  Louis  Med.  and  Surg.  Jour.,  J ekn.'89.i 

SFJVW,  NICHOLAS,  M.n,,  Ph.D,, 

Professor  of  Principles  of  Surgery  and  Surgical  Pathology  in  Rush  Medical  College,  Chicago. 

Surgical  Bacteriology.  In  one  handsome  octavo  of  259  pages,  with  13  plates, 
of  which  9  are  colored.     Cloth,  $1.75.     JvlsI  ready. 

The  immense  advances  made  by  surgery  during  recent  years  are  chiefly  due  to  the 
new  science  of  Bacteriology.  In  this  volume  is  collected  for  the  first  time,  and  in  avail- 
able form,  the  light  which  this  new  science  sheds  upon  surgery.  It  is  a  work  for  all  who 
deal  with  wounds  of  any  nature — for  the  general  practitioner  and  obstetrician  as  well  as 
for  the  surgeon. 

COATS,  JOSEPH,  M.  J>.,  E,  E,  JP,  S,, 

Pathologist  to  the  Olasgow  Western  Infirmary. 

A  Treatise  on  Pathology.  In  one  very  handsome  octavo  volume  of  829  pages, 
with  339  beautiful  illustrations.     Cloth,  $5.50  ;  leather,  $6.50. 


The  work  before  us  treats  the  subject  of  Path- 
ology more  extensively  than  it  is  usually  treated 
In  similar  works.  Medical  students  as  well  sis 
physicians,  who  desire  a  work  for  study  or  refer- 
ence, that  treats  the  subjects  in  the  various  de- 
partments in  a  very  thorough  manner,  but  without 
prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  any  with  whicn  we  are  acquainted.  It  sets 


forth  the  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,  the  changes  from  a  normal 
condition  effected  in  structures  by  disease,  and 
points  out  the  characteristics  of  various  morbid 
agencies,  so  that  they  can  be  easily  recognised.  But, 
not  limited  to  morbid  anatomy,it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions. — Cincinnati  Medical  News,  Oct.  1883. 


GREEN,  T,  HENBY,  M.  D., 

Lecturer  on  Pathology  and  Morbid  Anatoviy  at  Charing-Cross  Hospital  Medical  School,  London, 

Pathology  and  Morbid  Anatomy.    New  (sixth)  American  from  the  seventh 
revised  English  edition.     In  one  octavo  vol.  of  500  pp.,  with  150  engravings.     In  Press. 

WOODHEAH,  G.  SIMS,  M,  H.,  eTm.  C.  P,  E., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.     A  Manual  for  Students  and  Practitioners.     In  one  beau- 
tiful octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.     Cloth,  $6.00. 

It  forms  a  real  guide  for  the  student  and  practi- I  themselves  with  this  manual.  The  numerous 
tioner  who  is  thoroughly  In  earnest  in  his  en-  drawings  are  not  fancied  pictures,  or  merely 
deavor  to  see  for  himself  and  do  for  himself.  To  schematic  diagrams,  but  they  represent  faithfully 
the  laboratory  student  it  will  be  a  helpful  com-  '  the  actual  images  seen  under  the  microscope. 
panion,  and  all  those  who  may  wish  to  familiarize  {  The  author  merits  all  praise  for  having  produced 
themselves  with  modern  methods  of  examining  a  valuable  work. — Medical  Record,  May  31,  1884. 
morbid  tissues   are    .strongly  urged    to    provide  ) 

SCHAFER,  EHWARD  A.,  F.  R,  S„ 

Assistant  Professor  of  Physiology  in  University  College,  London, 

The  Essentials  of  Histology.      In  one  octavo  volume  of  246  pages,  with 

281  illustrations.     Cloth,  $2.25. 


This  admirable  work  was  greatly  needed.  It 
has  been  written  with  the  object  of  supplying 
the  student  with  directions  for  the  microscopical 
examination  of  the  tissues,  which  are  given  in  a 
clear  and  understandable  way.  Although  espe- 
cially adapted  for  laboratory  work,  at  the  same 


time  it  is  intended  to  serve  as  an  elementary 
text-book  of  histology,  comprising  all  the  essen- 
tial facts  of  the  science.  The  author  has  recom- 
mended only  those  methods  upon  which  long  ex- 
perience has  proved  that  fiill  dependence  can  b« 
placed. —  The  Phyneian  and  Surgeon,  July,  1887. 


KLEIN,  E,,  M.  n.,  F,  R.  S,, 

Joint  Lecturer  on  General  Anat.  and  Phya.  in  the  Med.  School  of  St.  Bartholomew's  Hotp.,  London. 

Elements  of  Histology.     Fourth  edition.    In  one  12mo.  volume  of  376  pages, 
with  194  illus.     Limp  clf)th,  $1.75.     Jii.s(  rrxidy.     See  Stud/m(^  Series  of  Manuals,  page  4. 

index  affords  a  reaily  reference  to  the  histology  of 
every  tissue  atul  orKan,  and  presents,  at  the  sam6 
time,  a  complete  glossary  of  thescientirtc  terms.— 


Provincial  Medical  Jinimal,  May  1, 1880. 


Considered  with  regard  to  its  cont<nts.  It  can 
only  be  looked  on  as  a  large  and  comprehensive 
volume.  New  and  original  illustrations  have  Ix-i-n 
added,  with  the  help  oi  which  the  structureof  each 
tissue  becomes  clear  lo  the  reader.    A  coplouB 

PEFFER,  A,  J.,  mTbTTM^S.,  F,  R.  C.  8., 

Surgeon  and  Lecturer  at  St.  Mari/'s  Hospxtal,  Ijondon. 

Surgical  Pathology.     In  one  i)<)cket-8ize  12rao.  volume  of  511  pimes,  with  81 
illustrations.  Limp  cloth,  re(l  eilges,  $2.00.     See  SlwUnis'  SerUs  of  Manuals,  |)age  4. 

Its  form  Is  practical  Its  language  l«  clear,  and  I  In  It  nothing  that  Is  unnecesHarv.  The  Hat  ol 
the  information  wet  f-.rth  U  w.-ir-Rrrangpd,  w.-ll-  subjects  coveri.  the  whole  range  of  surgery.— ^•lo 
Indexed  and  well-illustrated.  The  Bludent  will  find  |  Vork  Medical  Journal,  May  31, 1884. 


14 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


FLINT,  AUSTIN,  M.  D.,  LL.  D. 

Prof,  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med.  in  Bellevue  Hospital  Medical  College,  N.  7. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  of  Medicine.  New  (sixth)  edition,  thoroughly  re- 
vised and  rewritten  by  the  Author,  assisted  by  William  H.  Welch,  M.  D.,  Professor  of 
Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Flint,  Jr.,  M.  D.,  LL.  D., 
Professor  of  Physiology,  Bellevue  Hospital  Medical  College,  N.  Y.  In  one  very  handsome 
octavo  volume  of  1160  pages,  with  illustrations.  Cloth,  |5.50J  leather,  $6.50;  very 
handsome  half  Russia,  raised  bands,  $7.00. 


A  new  edition  of  a  work  of  such  established  rep- 
atationas  Flint's  Medicine  needs  but  few  words  to 
commend  it  to  notice.  It  may  in  truth  be  said  to 
embody  the  fruit  of  his  labors  in  clinical  medicine, 
ripened  by  the  experience  of  a  long  life  devoted  to 
Its  pursuit.  America  may  well  be  proud  of  having 
produced  a  man  whose  indefatigable  industry  and 

?;ifts  of  genius  have  done  so  much  to  advance  med- 
cine;  and  all  English-reading  student.i  must  be 
frateful  for  the  work  which  he  has  left  behind  him. 
t  has  few  equals,  either  in  point  of  literary  excel- 
lence, or  of  scientific  learning,  and  no  one  can 
study  its  pages  without  being  struck  by  the  lu- 
cidity and  accuracy  which  characterize  them.  It 
Is  qualities  such  as  these  which  render  it  so  valu- 
able for  its  purpose,  and  give  it  a  foremcst  place 
among  the  text-books  of  this  generation. — The 
London  Lancet,  March  12, 1887. 

No  text-book  on  the  principles  and  practice  of 
medicine  has  ever  met  in  this  country  with  such 


general  approval  by  medical  students  and  practi- 
tioners as  the  work  of  Professor  Flint.  In  all  the 
medical  colleges  of  the  United  States  it  is  the  fa- 
vorite work  upon  Practice;  and,  as  we  have  stated 
before  in  alluding  to  it,  there  is  no  other  medical 
work  that  can  be  so  generally  found  in  the  libra- 
ries of  physicians.  In  every  state  and  territory 
of  thisjvast  country  the  book  that  will  be  most  likely 
to  be  found  intheoflficeof  amedical  man,  whether 
in  city,  town,  village,  or  at  some  cross-roads,  Is 
Flint's  Practice.  We  make  this  statement  to  a 
considerable  extent  from  personal  observation,  and 
it  is  the  testimony  also  of  others.  An  examina- 
tion shows  that  very  considerable  changes  have 
been  made  in  the  sixth  edition.  The  work  may  un- 
doubtedly be  regarded  as  fairly  representing  the 
present  state  of  the  science  of  medicine,  and  as 
reflecting  the  views  of  those  who  exemplify  in 
their  practice  the  present  stage  of  progress  of  med- 
ical art. — Cincinnati  Medical  News,  Oct.  1886. 


HARTSHORNE,  SENRY,  M.  !>.,  LL.  !>., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.     Cloth,  $2.75 ;  half  bound,  $3.00. 

Within  the  compass  of  600  pages  it  treats  of  the 
history  of  medicme,  general  pathology,  general 
symptomatology,  and  physical  diagnosis  (mcluding 


laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  it  is  one  of  the  best 
of  its  kind  that  we  have  seen. — Glasgow  Medical 
Journal,  Nov.  1882. 

An  indispensable  book.    No  work  ever  exhibited 
a  better  average  of  actual  practical  treatment  than 


this  one;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials, as  the  name  suggests,  are  not  intended  to 
supersede  the  text-books  of  Flint  and  Bartholow, 
but  they  are  the  most  valuable  in  affording  the 
means  to  see  at  a  glance  the  whole  literature  of  any 
disease,  and  the  most  valuable  treatment. — Chicago 
Medical  Journal  and  Examiner,  April,  1882. 


BRISTOWE,  JOHN  STEM,  M,  !>.,  F.  R.  C,  P,, 

Physician  and  Joint  Lecturer  on  Medicine  at  St.  Thomas'  Hospital,  London. 
A  Treatise  on  the  Practice  of  Medicine.    Second  American  edition,  revised 
by  the  Author.    Edited,  with  additions,  by  James  H.  Hutchinson,  M.D.,  physician  to  the 
Pennsylvania  Hospital.     In  one  handsome  octavo  volume  of  1085  pages,  with  illustrations. 
Cloth,  $5.00 ;  leather,  $6.00. 


The  book  is  a  model  of  conciseness,  and  com- 
bines, as  successfully  as  one  could  conceive  it  to 
be  possible,  an  encyclopsedic  character  with  the 
smallest  dimensions.  It  differs  from  other  admi- 
rable text-books  in  the  completeness  with  which 
it  covers  the  whole  field  of  medicine. — Michigan 
Medical  News,  May  10,  1880. 

His  accuracy  in  the  portraiture  of  disease,  his 
care  in  stating  subtle  points  of  diagnosis,  and  the 
faithfully  given  pathology  of  abnormal  processes 
have  seldom  been  surpassed.  He  embraces  many 
diseases  not  usually  considered  to  belong  to  theory 


and  practice,  as  skin  diseases,  syphilis  and  insan- 
ity, but  they  will  not  be  objected  to  by  readers,  as 
he  has  studied  them  conscientiously,  and  drawn 
from  the  life. — Medical  and  Surgical  Reporter,  De- 
cember 20,  1879. 

The  reader  will  find  every  conceivable  subject 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  style  at  once  clear,  interesting  and 
concise.  The  additions  made  by  Dr.  Hutchinson 
are  appropriate  and  practical,  and  greatly  add  to 
its  usefulness  to  American  readers. — Buffalo  Med- 
ical and  Surgical  Journal,  March,  1880. 


WATSON,  SIR  THOMAS,  M,  D., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 
from  the  fifth  English  edition.  Edited,  with  additions,  and  190  illustrations,  by  Henry 
Hartshorne,  A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
In  two  large  octavo  volumes  of  1840  pages.     Cloth,  $9.00  ;  leather,  $11,00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  Hudson,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.    Cloth,  82.50. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  0.  C.    In  one  8vo.  vol.  of  354  pp.    Cloth,  $2.26. 


LA  ROCHE  ON  YELLOW  FEVER,  considered  in 

its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.    Cloth,  87.00. 


A  CENTURY  OF  AMERICAN  MEDICINE,  1776—1876.    By  Drs.  E.  H.  Claeke,  H.  J. 
BioEiow,  8.  D.  Geoss,  T.  G.  Thomas,  and  J.  S.  Billinos.    In  one  12mo.  volume  of  370  pages. 


Lea  Brothers  &  Co.'s  Publications — System  of  Med. 


15 


For  Sale  by  Subscription  Only. 


A  System  of  Practical  Medicine. 

BY  AMERICAN  AUTHORS. 

Edited  by  WILLIAM   PEPPER,  M.  D.,  LL.  D., 

PROVOST  AND  PROFESSOR  OP  THE  THEORY  AND  PRACTICE  OF  MEDICINE  AND  OF 
CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA, 

Assisted  by  Louis  Starr,  M.  D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania, 

The  complete  work,  in  five  volumes,  containing  5573  pages,  with  198  iUtistrations,  is  now  ready. 
Price  per  volume,  cloth,  $5;  leather,  $6 ;  half  Russia,  raised  bands  and  open  back,  $7. 


In  this  great  work  American  medicine  is  for  the  first  time  reflected  by  its  worthiest 
teachers,  and  presented  in  the  full  development  of  the  practical  utility  which  is  its  pre- 
eminent characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  for  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  to  each  author  has  been 
assigned  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientific  and  practical  knowledge.  The 
practitioner  wDl  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  and  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  found  most 
eflBcient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5600  beautifully  printed  pages,  and  embodying  the  matter  of  about  l5  ordinary 
octavos.     Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

A   detailed  prospectus  will  be  sent  to  any  address  on  application  to  the  publishers. 


These  two  yolumes  bring  this  admirable  work 
to  a  close,  and  fully  sustain  the  high  standard 
reached  by  the  earlier  volumes;  we  have  only 
therefore  to  echo  the  eulogium  pronounced  upon 
them.  We  would  warmly  congratulate  the  editor 
and  his  collaborators  at  the  conclusion  of  their 
laborious  task  on  the  admirable  manner  in  which, 
from  first  to  last,  they  have  performed  their  several 
duties.  They  have  succeeded  in  producing  a 
work  which  will  long  remain  a  standard  work  of 
reference,  to  which  practitioners  will  look  for 
guidance,  and  authors  will  resort  for  facts. 
From  a  literary  point  of  view,  the  work  is  without 
any  serious  blemish,  and  in  respectof  production, 
it  has  the  beautiful  finish  that  Americans  always 
give  their  works. — Edinburgh  MedicalJournal,J&n. 
587. 

•  •  Thegreatestdistinctively  American  work  on 
the  practice  of  medicine,  and,  indeed,  the  super- 
lative adjective  would  not  be  inappropriate  were 
even  all  other  productions  placed  in  comparison. 
An  examination  of  the  five  volumes  is  sufflcient 
to  convince  one  of  the  magnitude  of  the  enter- 
prise, and  of  the  success  which  has  attended  Its 
fulfilment.— r/ie  Maiienl  Age,  July  2ti,  1«hG. 

This  huge  volume  forms  a  fitting  I'lose  to  the 


physicians  who  are  acquainted  with  all  the  varie- 
ties of  climate  in  the  United  States,  the  character 
of  the  soil,  the  manners  and  customs  of  the  peo- 
ple, etc.,  it  is  peculiarly  adapted  to  the  wants 
of  American  practitioners  of  medicine,  and  it 
seems  to  us  that  every  one  of  them  would  desire 
to  have  it.  It  has  been  truly  called  a  "Complete 
Library  of  Practical  Medicine,"  and  the  general 
practitioner  will  require  little  else  in  his  round 
of  professional  duties. — Cincinnati  Medical  yewi, 
March,  188G. 

Each  of  the  volumes  is  provided  with  a  most 
copious  index,  and  the  work  altogether  promfsea 
to  be  one  which  will  add  much  to  the  medical 
literature  of  the  present  century,  and  reflect  great 
credit  upon  the  scholarship  and  practical  acumen 
of  its  authors.— 77ie  Lo'uion  Lancit,  Oct.  ,J,  l88.^. 

The  feeling  of  proud  satisfaction  with  which  the 
American  profession  se«s  this,  Itj*  representative 
system  of  practical  medicine  issueil  to  the  medi 
cal  world,  is  fully  justified  by  the  character  of  the 
work.  The  entire  ca-te  of  the  Hy-tteni  is  In  keep- 
ing with  the  best  thoughts  of  the  leaclers  ami  fol- 
lowers of  our  home  school  of  tnedlcine,  and  the 
combination  of  the  scientific  study  of  disease  and 
the  practical  application  of  exact  and  experlmen- 


freat  system  of  medicine  which  In  so  short  a  time  i  tal  knowledge  to  the  treatment  of  human  mal- 
as  won  so  high  a  place  in  medical  literature,  and  a<lles,  maken  every  one  of  us  nhare  In  the  pride 
has  done  such  credit  to  the  profession  in  this  i  that  has  welcomed  Dr.  Pepper's  labors.  Sheared 
country.     A  "  "  "'  "^  ~         n-i...   <i.-"  .~.. 


mong  the  twenty-three  contributors  1  of  the   prolixity   tha 
Ties    of    the   leading  neurologists  In  j  Oerman  school,  the 


that  wearies  the  readers  of  the 


are   the   names    of    the   leading  neurologists  In  i  Oerman  school,  the    articles    glean    these  same 
America,  and  most  of  the  work  In  the  volume  Is  of  i  fields  for  all  that  Is  valuable.      It   Is  the  outcome 


the   highest  order.— Boalon  Medical  and  Surgical 
Journal,  July  21, 1887. 

We  consider  it  one  of  the  grandest  works  on 
Practical  Medicine  In  the  English  language.  It  Is 
a  work  of  which  the  profession  of  this  country  can 


feel    proud.     Written    exclusively   by  American    eil  Juurnat,  Se^tt.  ISSO, 


of  American  brains,  and  Is  marked  throughout 
by  much  of  the  sturdy  Imlepemlence  of  tliought 
and  originality  that  Is  a  national  characterUtlO. 
Yet  nowhere  Is  there  lack  of  study  of  the  moM 
advanced  views  of  the  day.— JVor</»  Carolina  Jftdt- 


16  Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 

FOTHERGILL,  J,  M.,  M,  !>.,  Edin,,  M,  R,  C,  B.,  Lond,, 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics. New  (third)  edition.  In  one  8vo.  vol.  of  661  pages.  Cloth,  |3,75 ;  leather,  $4,75. 
To  have  a  description  of  the  normal  physiologi-  '  This  is  a  wonderful  book.  If  there  be  such  a 
cal  processes  of  an  organ  and  of  the  methods  of  I  thing  as  "  medicine  made  easy,"  this  is  the  work  to 
treatment  of  its  morbid  conditions  brought  j  accomplish  this  result. —  Va.  Med.  Month.,  3une,'87. 
together  in  a  single  chapter,  and  the  relations!  It  is  an  excellent,  practical  work  on  therapeutics, 
between  the  two  clearly  stated,  cannot  fail  to  prove  j  well  arranged  and  clearly  expressed,  useful  to  the 
a  great  convenience  to  many  thoughtful  but  busy  |  student  and  young  practitioner,  perhaps  even  to 
physicians.  The  practical  value  of  the  volume  is  the  old. — Dublin  Journal  of  Medical  Science,  March, 
greatly  increased    by  the  introduction  of  many    18S8. 

prescriptions.  That  the  profession  appreciates  We  do  not  know  a  more  readable,  practical  and 
that  the  author  has  undertaken  an  important  work  useful  work  on  the  treatment  of  disea.se  than  the 
and  has  accomplished  it  is  shown  by  the  demand  one  we  have  now  before  us. — Pacific  Medical  and 
for  this  third  edition. — N.  Y.  Med.  Jour.,  June  11,'87.    Surgical  Journal,  October,  1887. 


VAUGSAN,  VICTOR  C,  Ph.  !>.,  M,  X)., 

Prof,  of  Phys.  and  Path.  Chem.  and  Assoc.  Prof,  of  Therap.  and  Mat.  Med.  in  the  Univ.  of  Mich. 

and  WOVT,  FREDERICK  G.,  M,  D. 

Instructor  in  Hygiene  and  Phys.  Chem.  in  the  Univ.  of  Mich. 

Ptomaines  and  Leucomaines,  or  Putrefactive    and   Physiological 
Alkaloids.     In  one  handsome  12mo.  volume  of  311  pages.     Just  ready.     Cloth,  $1.75. 

This  book  is  what  has  been  wanted  for  some  j  observers  and  experimenters  on  micro-organisms, 
years  by  the  medical  profession.  The  subject  of  1  and  to  trace  the  relationship  of  cause  and  effect 
ptomaines  and  leucomaines,  80  far  as  their  disease- I  of  the  putrefacative  alkaloids.  We  congratulate 
producing  relations  are  concerned,  has  been  under  I  the  authors  upon  the  successful  presentation  of 
special  study  scarcely  more  than   a  decade,   but  |  the  current  views  on  the  subject  in  such  manner 


within  that  period  facts  have  been  discovered 
upon  which  theories  of  permanent  standing  have 
been  built,  until  now  the  practitioner  is  far  be- 
hind the  times  if  he  does  not  appreciate  the 
importance  of  ptomaines.  This  is  the  first  attempt 
made  to  collect   into  book  form  the  results  of 


as  to  make  them  easily  comprehensible,  while  to 
the  practitioner,  after  he  has  carefully  read  the 
book,  it  will  serve,  also,  as  a  frequent  reference 
work,  because  of  the  technical  information  it  gives. 
Va.  Medical  Monthly,  Sept.  1888. 


BEYNOmS,  J.  RUSSELZ,  M,  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 
A  System  of  Medicine.  With  notes  and  additions  by  Henry  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  doublccolumned  pages,  with  317  illustra- 
tions. Price  per  volume,  cloth,  $5.00 ;  sheep,  $6.00 ;  very  handsome  half  Russia,  raised  bands, 
$6.50.     Per  set,  cloth,  $15;  leather,  $18;  half  Russia,  $19.50.    Sold  only  by  subscription. 

STILLE,  ALFRED,  M.  X).,  IL.  I),, 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 
Cholera :   Its  Origin,  History,  Causation,  Symptoms,  Lesions,  Prevention  and  Treat- 
ment. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart.  Cloth,  $1.25. 

FINLAYSONf  JAMES,  M,  J>.,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Olasgow  Western  Infirmary,  etc. 

Clinical  Manual  for  the  Study  of  Medical  Cases.  With  Chapters 
by  Prof.  Gairdner  on  the  Physiognomy  of  Disease ;  Prof.  Stephenson  on  Diseases  of 
the  Female  Organs ;  Dr.  Robertson  on  Insanity ;  Dr.  Gemmell  on  Physical  Diagnosis ; 
Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor  on  Case- 
taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  New  edition. 
In  one  12mo.  volume  of  682   pages,  with   158   illustrations.    Cloth,  $2.50. 


This  manual  is  one  of  the  most  complete  and 
perfect  of  its  kind.  It  goes  thoroughly  into  the 
question  of  diagnosis  from  every  possible  point. 
It  must  lead  to  a  thoroughness  of  observation,  an 
examination  in  detail  of  every  scientific  appliance, 


and  a  study  of  means  to  the  end  which  cannot 
fail  in  laying  an  excellent  foundation  for  the 
student  for  future  success  as  an  able  diagnostician. 
—Medical  Record,  August  13, 1887. 


FENWICK,  SAMUEL,  M.  D,, 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  Englisli  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.     Cloth,  $2.25. 

HABERSHOJ^,  S,  O.,  M.  D., 

Senior  Physician  to  and  late  Lect.  on  Principles  and  Practice  of  Med.  at  Ouy^s  Hospital,  London. 
On  the  Diseases  of  the  Abdomen ;     Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  (Esophagus,  Csecum,  Intestines  and  Peritoneum.  Second 
American   from  third  enlarged  and  revised  English  edition.     In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.     Cloth,  $3.50. 

TAJSIWER,  THOMAS  HAWKES,  M,  D, 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
from  the  second  London  edition.  Revised  and  enlarged  by  Tilbttry  Fox,  M.  D. 
In  one  small  12mo.  volume  of  362  pages,  with  illustrations.    Cloth,  $1.50. 


Lea  Brothebs  &  Co.'s  Publications — Hygiene,  Electr.,  Pract.        17 


BARTHOLOW,  ROBERTS,  A,  M.,  M.  D.,  ZL,  D., 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  CoU.  of  Phila.,  etc. 
Medical  Electricity.     A  Practical  Treatise  on  the  Applications  of  Electricitj 
to  Medicine  and  Surgery.     New  (third)  edition.     In  one  very  handsome  octavo  volume  of 
308  pages,  with  110  illustrations.     Cloth,  $2.50. 
The  fact  that  this  work  has  reached  its  third  edi-  '  should  read  it,  especially  when  it  is  recalled  what 

possibilities  lie  in  the  path  of  the  further  study  of 
the  therapeutics  of  electricity.  Dr.  Bartholow  has 
here  presented  the  profession  with  a  concise  work 

^.  jj    ^        ^  -     :^ that,  beginning  with  elementary  descriptions  and 

The  matter  added  to  the  present  edition  embraces    principles,  gradually  grows,  page  by  page,  into  a 
the  rnost  recent  advances  in  electrical  treatment,    magnificently  practical  treatise,  describing' opera- 


tion in  six  years,  and  that  it  has  been  kept  fully 
abreast  with  the  increasing  use  and  knowledge  of 
electricity,demonstrates  its  claim  to  be  considered 
a  practical  treatise  of  tried  value  to  the  profession. 


The  illustrations  are  abundant  and  clear,  and  the 
work  constitutes  a  full,  clear  and  concise  manual 
well  adapted  to  the  needs  of  both  student  and 
practitioner. —  The  Medical  Kews.  May  14,  1887. 

This  "practical  treatise  on  the  applications  of 
electricity  to  medicine  and  surgery"  has  grown  to 
be  80  important  a  work  that  every  practitioner 


.    .  ,  , -- oing  opera- 

tions in  detail,  and  giving  records  of  successes 
that  prove  electricity  to  be  marvellous  a.<  a  curative 
agent  in  many  forms  of  disease.  The  doctor  can- 
not now  do  better  than  to  possess  him.self  of  Dr. 
Bartholow's  treatise,  just  as  it  is.— Virginia  Medi- 
col  Monthly,  Jane,  1887. 


RICSARDSOIf,  B,  IF.,  M,D,,  LL.  JO.,  F,R,8,, 

Fellow  of  the  Ropal  College  of  Physicians,  London. 

Preventive  Medicine.     In  one  octavo  volume  of  729  pages.    Cloth,  $4;  leather, 
$5;  very  handsome  half  Russia,  raised  bands,  $5.50. 

tiitj  question  of  disease  is  comprehensive,  masterly 
and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable.— T^e 
American  Journal  of  the  Medical  Sciences,  April,  1884. 
This  is  a  book  that  will  surely  find  a  place  on  the 


Dr.  Richardson  has  succeeded  in  producing  a 
work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  character,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.    He  evinces  the  happy 

faculty  or  extracting  the  pith  of  what  is  known  on  ^  ^  _.., 

the  subject,  and  of  presenting  it  Jn  a  most  simple,  !  table  of  every  progressive  phy.«ician.  'fothemedi" 
intelligent  and  practical  form.  There  is  perhaps  ]  cal  profession,  whose  duty  is  quite  as  much  to 
no  similar  work  written  for  the  general  public  i  prevent  as  to  cure  disease,  the  book  will  be  a  boon, 
that  contains  such  acomplete,  reliable  and  instruc-  '  —Boston  Medical  and  Surgical  Journal,  March  G,  '84, 
tive  collection  of  data  upon  the  disea.ses  common        r^.  ^       .■  •  ....<. 

to  the  race,  their  origins,  causes,  and  the  mea.sures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly  ;  the  discussion  of 


The  treatise  contains  a  vast  amount  of  solid,  val- 
uable hygienic  information.— Jtfedjca^  aiui  Surgical 
Reporter,  Feb.  23, 1884. 


TSJS  TEAR-BOOK  OF  TREATMENT  FOR  1889. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine.    In  one  12mo.  volume  of  349  pages,  bound  in  limp  cloth,  $1.25.     JuM  ready. 

^*^  For  special  commutations  with  periodicals  see  page  2. 

THE  TEAR- BOOK  OF  TREATMENT  FOR  1887. 

Similar  to  above.     12mo.,  341  pages.     Limp  cloth,  $1.25. 


This  is  one  of  the  most  valuable  books  for  its 
price  which  is  published  in  this  or  any  coun- 
try. It  contains  a  summary  of  the  changes  in 
medical  practice,  the  new  remedies  introduced, 
and  the  experience  with  them  and  with  others 
which  have  been  longer  in  use,  during  the  year 
1887,  made  up  from  the  reading  and  observation 
of  a  number  of  very  capable  men.  The  classifica- 
tion is  according  to  diseases,  so  that  one  who  con- 


sults these  pages  can  obtain  in  a  few  minutes  an 
excellent  idea  of  the  present  status  of  therapeu- 
tics in  regard  to  any  given  ailment.  The  book 
also  has  a  good  index,  by  means  of  which  the 
reader  may  ascertain  the  different  diseases  for 
which  any  particular  drug  has  been  used  during 
the  year  past. — Medical  and  Surgical  Reporter, 
April  14, 1888. 


TSE  TEAR-BOOK  OF  TREATMENT  FOR  1886. 

Similar  to  that  of  1887  above.     12mo.,  320  pages.     Limp  cloth,  $1.25. 

SCHREIBER,  DR.  JOSEPH. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Wai-tek  Mendei>ion,  M.  D.,  of  New  York.  In  one  handwime 
octavo  volume  of  274  pages,  with  117  fine  engravings.     Just  ready.     Cloth,  $2.75. 

This  is  a  work  abounding  in  common  .sense,  a  I  cise,  after  which  there  is  a  detailed  account  of  the 
book  that  sweeps  away  a  great  deal  of  nonsense  '  results  of  treatment  of  different  disca-es  by  these 


by  which  a  simple  matter  has  been  made  obscure, 
a  volume  that  ought  to  be  read  by  ev«-ry  one  inter- 
ested in  modern  therapeutics.  The  work  gives 
admirable  directions  for  the  employment  of  mas- 
sage, and  capital  descriptions  of  methodical  exer- 

8TURGE8'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  BelngaRuide  to 
the  Investigation  of  Disease.  In  one  handsome 
12mo.  volume  of  1'27  pages.     Cloth,  81.26. 

DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  8.  Daviii 
M.  D.  Edited  by  Frank  H.  Davih,  M.  D.  Second 
edition.     12mo.  287  pages.     Cloth,  11.76. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  pages.    Cloth,  t2.50. 


methods.  A  full  bibliography  adds  to  the  value  of 
the  volume,  which  can  he  recommended  an  one  of 
the  best  on  the  subjects  with  which  it  deals. — 
Edinburgh  Medical  Journal,  April,  1888. 


PAVY'S  TREATISE  ON  THE  FUNCTION  OP  DI- 
GESTION;  it-  r>i«orden»  and  their  Treatment. 

From  tV- '  '  '>ndon  edition.     In  one  octavo 

Toltinic  Cloth.  fJ.iK). 

BARL(i\  I.   OK   THE  PRACTICE  OF 


MKDK  ..>.-,      >,,,,:     -'  '■ 

M.  I».     1  vol.  8VO.    I 
CHAMMKRH'MANIA 

IN    HEALTH    A.NL  ...  . 

some  octavo  volume  of.V' 
HOLLANDS  MEDICAL  > 

TIONS.  I  vol.  8VO..  pp.  4.t. 


f'V  D.   F.  CowDit, 

..  t--'..Vl. 

VND  REGIMEN 
'•'      ■■'    'land- 

LEO- 


18         Lea  Brothers  &  Co.'s  Publications — Tliroat,  Lungs,  Heart. 


FLINT,  AUSTIN,  M.  D.,  LL,  !>., 

Profeisor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  7. 

A.  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fourth  edition.  In  one 
handsome  royal  12mo.  volume  of  278  pages,  with  14  illustrations.    Cloth,  $1.75. 


The  original  work  done  by  Dr.  Flint  in  the  devel- 
opment of  the  art  of  physical  diagnosis  will  always 
make  this  manual  an  authority  on  this  subject. 
Among  all  the  works  issued  on  this  topic  during 
the  last  few  years,  none  exceeds  this  one  in  sim- 
plicity and  completeness.    The  fact  that  it  has 


passed  through  four  editions  attests  its  popularity* 
There  is  a  tendency  among  physical  diagnosti- 
cians to  make  altogether  too  many  varieties  of 
morbid  chest  sounds,  and  especially  of  rales.  The 
conciseness  of  Dr.  Flint's  Manual  is  one  of  its  chief 
advantages  — Medical  Record,  June  IG,  1888. 


BY  THE  SAME  A  UTHOR. 


A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.     In  one  handsome  octavo  volume  of  591  pages.     Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.     In  one  octavo  volume  of  442  pages.    Cloth,  $3.50. 

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 
Diseases  of  the  Heart.     Second  revised  and  enlarged  edition.    In  one  octavo  volume 

of  550  pages,  with  a  plate.    Cloth,  $4. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.     Cloth,  $1.38. 


BROWNE,  LENNOX,  F.  B,  C.  S.,  E., 

Senior  Physician  to  the  Central  London  Throat  and  Ear  Hospital. 

A  Practical  Guide  to  Diseases  of  the  Throat  and  Nose,  including 
Associated  Affections  of  the  Ear.  With  120  illustrations  in  color,  and  200  en- 
gravings on  wood  designed  and  executed  by  the  Author.  New  (second)  and  enlarged 
edition.     In  one  imperial  octavo  volume  of  628  pages.     Cloth,  $6. 


Mr.  Browne's  book  can  be  recommended  to 
students  and  still  more  to  practitioners  as  a  clear, 
sound  and  practical  guide  to  the  diagnosis  and 
treatment  of  diseases  of  the  throat.  His  experi- 
ence is  not  only  large,  but  ripe,  and  he  gives  his 
readers  the  full  benefit  of  it.    A  particularly  praise- 


worthy feature  is  that  from  beginning  to  end  Mr. 
Browne,  whilst  giving  due  prominence  to  local 
measures,  never  fails  to  insist  on  the  necessity  of 
supplementing  these  by  proper  constitutional 
treatment. — London  Medical  Beeorder,  May,  1888. 


8EILEB,  CABL,  M.  D., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  New  (third)  edition.  In  one  handsome  royal  12mo. 
volume  of  373  pages,  with  101  illustrations  and  2  colored  plates.   Cloth,  $2.25.    Just  ready. 

will  be  found  throughout  the  volume.    Two  care- 


Practical  points,  to  which  the  book  is  limited, 
have  been  considered  as  concisely  as  possible, 
making  the  work  an  excellent  one  for  ready  refer- 
ence on  the  subjects  treated.    Numerous  additions 


fully-executed  colored  plates  will  be  found  of 
assistance  to  the  student  and  practitioner.— &'out/»- 
ern  Practitioner,  April,  1889. 


GBOSS,  S.  2>.,  M,I>,,  LL.D,,  D.C.L.  Oxon,,  LL,I>.  Cantab. 

A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.    In  one 

octavo  volume  of  452  pages,  with  59  illustrations.     Cloth,  $2.75. 


COHEN,  J.  SOLI8,  M.  D., 

Lecturer  on  Laryngoscopy  and  Dijieases  of  the  Throat  and  Chest  in  the  Jeffeirson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  (Esophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.     Preparing. 


BBOADBENT,  W.  H.,  M,  D,,  F,  B,  C.  F,, 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary's  Hospital. 
The  Pulse.    In  one  12mo.  volume.   Preparing.    See  Series  of  Clinical  Manuals,  page  4. 

FULLER  ON  DISEASES  OF  THE  LUNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  $3.50. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  Americau  edi- 
tion.    In  1  vol.  8vo.,  416  pp.    Cloth,  83.00. 

BLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 


valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  pp.  158.    Cloth,  $1.25. 

SMITH  ON  CONSUMPTION ;  its  Early  and  Reme- 
diable Stages.    1  vol.  8vo.,  pp.  253.    Cloth,  $2.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.    Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.  In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.60. 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,  etc.     19 


BOSS,  JAMBS,  M.I>,,  F,R.C.P.,  LL.D,, 

Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 

A  Handbook  on  Diseases  of  the  Nervous  System.  In  one  octavo 
volume  of  725  pages,  with  184  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

This  admirable  work  is  intended  for  students  of  '  the  department  of  medicine  of  which  it  treats 
medicine  and  for  such  medical  men  as  have  no  time  Dr.  Ross  holds  such  a  high  scientific  posiHon  that 
for  lengthy  treatises.  In  the  present  instance  the  any  writings  which  bear  his  name  are  naturally 
duty  01  arranging  the  vast  store  of  material  at  the  expected  to  have  the  impress  of  a  powertui  intel- 
disposal  of  the  author,  and  of  abridging  the  de-  lect.  In  every  part  this  handbook  merits  the 
scription  of  the  different  aspects  of  nervous  dis-  highest  praise,  and  will  no  doubt  be  found  of  the 
eases,  has  been  performed  with  singular  skill  and  greatest  value  to  the  student  as  well  as  to  the  prao- 
the  result  is  a  concise  and  philosophical  guide  to  ;  titioner.— Edinburgh  MedicalJournal,  Jan.  1887. 

MITCHELL,  S.  WEIR,  M.  D., 

Physician  to  Orthopcedic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  System,  Phila.,  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  Women. 
Second  edition.     In  one  12mo.  volume  of  288  pages.     Cloth,  $1.75. 

No  work  in  our  language  develops  or  displays  |  teachings  the  stamp  of  authority  all  over  the 
more  features  of  that  many-sided  affection,  hys-  realm  of  medicine.  The  work  although  written 
teria,  or  gives  clearer  directions  for  its  differen-  |  by  a  specialist,  has  no  exclusive  character  and 
tiation,  or  sounder  suggestions  relative  to  its  I  the  general  practitioner  above  all  others  wilf  find 
general  management  and  treatment.  The  book  its  perusal  profitable,  since  it  deals  with  diseases 
IS  particularly  valuable  in  that  it  represents  in  '  which  he  frequently  encounters  and  must  essay 
the  main  the  author's  own  clinical  studies,  which  to  ir^sA.— American  Practitioner,  August  1885. 
have  been  so  extensive  and  fruitful  as  to  give  his  \  ' 

HAMILTON,  ALLAN  McLANJS,  M,  D., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlaekweWs  Island,  N.  T. 

Nervous  Diseases ;  Their  Description  and  Treatment.     Second  edition,  thoroughly 

revised  and  rewritten.    In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 

When  the  first  edition  of  this  good  book  appeared  j  characterized  this  book  as  the  best  of  its  kind  in 

we  gave  it  our  emphatic   endorsement,  and  the     any  language,  which  is  a  handsome  endorsement 

E resent  edition  enhances  our  appreciation  of  the  from  an  exalted  source.  The  improvements  in  the 
ook  and  its  author  as  a  safe  guide  to  students  of  new  edition,  and  the  additions  to  it,  will  justify  its 
clinical  neurology.  One  of  the  best  and  most  |  purchttse  even  by  those  who  possess  the  old.— 
critical  of  English  neurological  journals,  Brain,  has  i  Alienist  and  Neurologist,  April,  1882. 

TUKE,  DANIEL  HACK,  M,  n.. 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  revised  and  rewritten.  In  one  8vo.  vol.  of  467  pp.,  with  2  col.  plates.   Cloth,  $3. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomena  the  more  firmly 
has  he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.—iVeui  York  Medical  Journal  September  6, 1884. 


CLOUSTON,  THOMAS  S.,  M,  H.,  F,  B.  C.  P.,  i.  JB.  C.  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Foi^som,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  ^olums  o!  541 
pages,  with  eight  lithographic  plates,  four  of  which  are  beautifully  colored.     Cloth,  $4. 

The  practitioner  as  well  as  the  student  will  ac-  j  the  general  practitioner  in  guiding  him  to  a  diae- 
cept  the  plain,  practical  teaching  of  the  author  as  a  ]  nosis  and  indicating  the  treatment,  especially  fn 
forward  step  in  the  literature  of  insanity.    It  is  i  many  obscure  and  doubtful  cases  of  mental   dis- 


refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  ^:~ins;  the  bed 
siae  notes  upon  which  nis  experience  nas  been 
founded  and  his  mature  judgment  estahiisned. 
Such  clinical  observation.s  cannot  but  be  useful  to 


ease.  To  the  American  reader  Dr.  Folsom's  Ap- 
pendix  adds  greatly  to  the  value  of  the  work,  and 
will  m  t  ce  it  a  desirable  ad.iition  to  every  library. 
—American  Psychological  Jou'-nal,  July,  1884. 


|i^*Dr.  Folsora's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
108  pages     Cloth,  $1.50. 

SAVAGE,  GEOItGE~H,  M.  D,, 

Lecturer  on  Mental  Diseases  at  Ouy'a  Hospital,  Ltrndon. 
Insanity  and    Allied    Neuroses,   Practical  and   Clinical.     In  one  12mo.  vol. 
of  551  pages,  with  IS  illus.     Cloth,  $'2.00.     See  Series  of  Clinical  ManxuilM,  page  4. 

PLATFAIB,  W.  S.,  M.  D.VfTb.  C,  r. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.    In 

one  handsome  small  12rao.  volume  of  97  piiges.     Cloth,  $1.0(1. 

Blandford  on  Insanity  and  its  Treatment:    Ijeotureft  on  the  Treatment, 

Medical  and  Leital,  of  Insanp  Patl^nls.     In  one  very  tiandMom»«  octavo  voiiime. 

Jones'   Clinical   Observations   on   Functional    Nervous    Disorders. 

Second  American  Edition.     In  one  handsome  octavo  volume  of  H4()  pagen.     Cloth,  $l{.25. 


20 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


ASMBURST,  JOHN,  Jr.,  31,  D., 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

The  Principles  and  Practice  of  Surgery.  New  (fourth)  edition,  enlarged 
and  revised.  In  one  large  and  handsome  octavo  volume  of  1114  pages,  with  597  illustra- 
tions.    Cloth,  $6 ;  leather,  $7  ;  half  Kussia,  $7.50. 

As  with  Erichsea  so  with  Ashhurst,  its  position 
In  professional  favor  is  established,  and  one  has 
now  but  to  notice  the  changes,  if  any,  in  theory 


and  practice,  that  are  apparent  in  the  present 
as  compared  with  the  preceding  edition,  puolished 
three  years  ago.  The  work  has  been  brought  well 
up  to  date,  and  is  larger  and  better  illustrated  than 
before,  and  its  author  may  rest  assured  that  it  will 
certainly  have  a  "continuance  of  the  favor  with 
which  it  has  heretofore  been  received." — The 
American  Journal  of  the  Medical  Sciences,  Jan.  1886. 


Every  advance  in  surgery  worth  notice,  chroni- 
cled in  recent  literature,  has  been  suitably  recog- 
nized and  noted  in  its  proper  place.  Suffice  it  M) 
say,  we  regard  Ashhurst's  Surgery,  as  now  pre- 
sented in  the  fourth  edition,  as  the  best  single 
volume  on  surgery  published  in  the  English  lan- 
guage, valuable  alike  to  the  student  and  the  prac- 
titioner, to  the  one  as  a  text-book,  to  the  other  as 
a  manual  of  practical  surgery.     With  pleasure  we 

Sive  this  volume  our  endorsement  in  full. — New 
rleans  Medical  and  Surgical  Journal,  Jan.,  1886. 


GROSS,  S.  D.,  M,  D.,  LL,  J>.,  D.  C.  i.   Oxon.,  LL,  D, 
Cantab,, 

Emeritus  Professor  of  Su/rgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery:    Pathological,   Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.     In  two  large  and  beautifully- 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  $15;  half  Russia,  raised  bands,  $16 

Dr.  Gross'  Systtm  of  Surgery  has  long  been  the 
standard  work  on  that  subject  for  students  and 
practitioners. — London  Lancet,  May  10,  1884. 

The  work  as  a  whole  needs  no  commendation. 
Many  years  ago  it  earned  for  itself  the  enviable 


reputation  of  the  leading  American  work  on  sur- 
gery, and  it  is  still  capable  of  maintaining  that 
standard.  A  considerable  amount  of  new  material 
has  been  introduced,  and  altogether  the  distin- 
guished author  has  reason  to  be  satisfied  that  he 
has  placed  the  work  fully  abreast  of  the  state  of 
our  Knowledge. — Med.  Record,  Nov.  18, 1882. 


His  System  oj  Surgery,  which,  since  its  first  edi- 
tion In  1859,  has  been  a  standard  work  In  this 
country  as  well  as  in  America,  in  "the  whole 
domain  of  surgery,"  tells  how  earnest  and  labori- 
ous and  wise  a  surgeon  he  was,  how  thoroughly 
he  appreciated  the  work  done  oy  men  in  other 
countries,  and  how  much  he  contributed  to  pro- 
mote the  science  and  practice  of  surgery  in  his 
own.  There  has  been  no  man  to  whom  America 
is  so  much  indebted  in  this  respect  as  the  Nestor 
of  surgery. — British  Medical  Journal,  May  10,  1884. 


DRUITT,  ROBERT,  M,  R,  C,  S,,  etc. 

Manual  of  Modern  Surgery.  Twelfth  edition,  thoroughly  revised  by  Stan- 
ley Boyd,  M.  B.,  B.  S.,  F.  R.  C.  S.  In  one  8vo.  volume  of  965  pages,  with  373  illustra- 
tions.    Cloth,  $4 ;  leather,  $5. 


It  is  essentially  a  new  book,  rewritten  from  be- 
ginning to  end.  The  editor  has  brought  his  work 
up  to  the  latest  date,  and  nearly  every  subject  on 
wnich  the  student  and  practitioner  would  desire 
to  consult  a  surgical  volume,  has  found  its  place 
here.  The  volume  closes  with  about  twenty  pages 
of  formulae  covering  a  broad  range  of  practical 
therapeutics.  The  student  will  find  that  the  new 
Druitt  is  to  this  generation  what  the  old  one  was 
to  the  former,  and  no  higher  praise  need  be 
accorded  to  any  volume. — 3iorth  Carolina  Medical 
Journal,  October,  1887. 


Druitt's  Surgery  has  been  an  exceedingly  popu- 
lar work  in  the  profession.  It  is  stated  that  60,000 
copies  have  been  sold  in  England,  while  in  the 
United  States,  ever  since  its  first  issue,  it  has  been 
used  as  a  text-book  to  a  very  large  extent.  Dur- 
ing the  late  war  in  this  country  it  was  so  highly 
appreciated  that  a  copy  was  issued  by  the  Govern- 
ment to  each  surgeon.  The  present  edition,  while 
it  has  the  same  features  peculiar  to  the  work  at 
first,  embodies  all  recent  discoveries  in  surgery, 
and  is  fully  up  to  the  times.  Cincinnati  Malieal 
Neivs,  September,  1887. 


BALL,  CHARLES  B,,  M,  Ch.,  Huh,,  F,  R,  C.  S,  E,, 

Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital,  Dublin. 

Diseases  of  the  Rectum  and  Anus.  In  one  12mo.  volume  of  417  pages, 
with  54  engravings  and  4  colored  plates.  Cloth,  $2.25.  Just  ready.  See  Series  of  Clinical 
Manuals,  page  4. 


It  is  a  pleasure  to  read  an  exhaustive  and  well- 
arranged  book,  such  as  the  one  before  us.  It 
covers  all  the  ground,  and  yet  is  written  in  a  terse 
and  concise  style  that  makes  it  exceedingly  good 
reading.  The  work  is  far  in  advance  of  the  ordi- 
nary text-book  on  this  specialty.  It  is  very  com- 
plete, and  the  matter  is  all  of  practical  importance 
and  well  arranged.  The  writer  has  done  for  rectal 
surgery  what  Treves  in  the  companion  volume 


has  done  for  intestinal  obstruction,  and  both 
works  are  alike  creditable. — N.  Y.  Medical  Journal, 
Jan.  28,  1888. 

A  capital  book  in  a  capital  series  of  clinical 
manuals.  Thoroughly  practical,  it  is  both  compre- 
hensive and  condensed  and  the  possessor  of  it  will 
find  but  little  use  for  any  more  extended  work  on 
the  subject.  Mr.  Ball  is  a  most  sound  surgeon. — 
The  Medical  News,  Feb.  4, 1888. 


GIBJSTET,  V,  J*.,  M,  H,, 

Surgeon  to  the  Orthopaedic  Hospital,  New  York,  etc. 

Orthopaedic  Surgery.    For  the  use  of  Practitioners  and  Students, 
some  octavo  volume,  profusely  illustrated.     Preparing. 


In  one  hand- 


ROBERTS,  J,  B,,  M,  H,,  and  MORTON,  T,  S,  K,,  M,  H,, 

Professor  of  Anat&my  and  Surgery  in  the  Adjunct  Professor  of  Operative  Surgery  in  the 

Philadelphia\Polyclinie.  Philadelphia  Polyclinic. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students 
and  Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  aboat 
500  pages,  with  many  illustrations.    Preparing. 


Lea  Brothers  &  Co.'s  Publications — Surgery. 


21 


EBICHSEN,  JOHN  B,,  F,  H,  S,,  F.  B,  C.  S., 

Professor  of  Surgery  in  University  College,  London,  etc. 

The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.  From  the  eighth  and  enlarged  English  edition.  In  two  large  and 
beautiful  octavo  volumes  of  2316  pages,  illustrated  with  984  engravings  on  wood. 
Cloth,  $9;  leather,  raised  bands,  $11 ;  half  Russia,  raised  bands,  $12, 

We  have  always  regarded  "The  Science  and 
Art  of  Surgery"  as  one  of  the  best  surgical  text- 
books in    the    English  language,  and  this  eighth 


edition  only  confirms  our  previous  opinion.  We 
take  great  pleasure  in  cordially  commending  it  to 
our  retkders. —  ne  Medical  Xews,  April  11, 1885. 

For  many  years  this    classic    work   has  been 
made  by  preference  of   teachers    the    principal 


marked  the  progress  of  surgery  during  the  last 
decade  has  been  omitted.  The  illustrations  are 
many  and  executed  in  the  highest  style  of  art. 
— LouisviiJe  Medical  News,  Feb.  14,  1885. 

We  cannot  speak  too  highly  of  this  excellent 
work.  It  represents  the  most  advanced  and  settled 
views  in  regard  to  the  science  of  surgery,  and  will 
ever  be  found  a  faithful  guide  and  counsellor  in 


text-book  on  surgery  for  medical  students,  while  practice.— Canada  Lance<,  May,  1885. 
through  translations  into  the  leading  continental  It  appears  simultaneously  in  England,  America, 
languages  it  may  be  said  to  guide  the  surgical  Spain  and  Italy,  and  is  too  well  known  as  a  safe 
teachings  of  the  civilized  world.  No  excellence  guide  and  familiar  friend  to  need  further  com- 
of  the  former  edition  has  been  dropped  and  no  j  ment.— i^Mc  York  Medical  Journal,  March  28, 1886. 
discovery,    device    or   improvement    which    has  | 


BRYANT,  THOMAS,  F,  M,  C.  S,, 

Surgeon  and  Lecturer  on  Surgery  at  Chuy''s  Hospital,  London. 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.     In  one  large  and  very  handsome  imperial  octavo  volume^of  1040  pages,  with 
727  illustrations.     Cloth,  $6.50;  leather,  $7.50;  half  Eussia,  $8.00. 
The  fourth  edition  of  this  work  is  fully  abreast  '  enable  the  busy  practitioner  to  review  any  subject 

of  the  times.    The  author  handles  his  subjects  '  "  -.      . 

with  that  degree  of  judgment  and  skill  which  is 
attained  by  years  of  patient  toil  and  varied  ex- 
perience. The  present  edition  is  a  thorough  re- 
vision of  those  which  preceded  it, -with  much  new 
matter  added.  His  diction  is  so  graceful  and 
logical,  and  his  explanations  are  so  lucid,  as  to 

Elace  the  work  among  the  highest  order  of  text- 
ooks  for  the   medical   student.     Almost   every 
topic  in  surgery  is  presented  in  such  a  form  as  to 


in  every-day  practice  in  a  short  time.  No  time  is 
lost  with  useless  theories  or  superfluous  verbiage. 
In  short,  the  work  is  eminently  clear,  logical  and 
practical. — Chicago  Medical  Journal  and  Examiner, 
April,  1886. 

This  book  is  essentially  what  it  purports  to  be, 
viz.:  a  manual  for  the  practice  of  surgery.  It  is 
peculiarly  well  fitted  for  the  student  or  bu.«y  general 
practitioner.— r/ie  Medical  A'eus,  August  15, 188S. 


TREVES,  FREDERICK,  F.  R,  C,  S., 

Hunterian  Professor  at  the  Royal  College  of  Surgeons  oj  England. 
A  Manual    of   Surgery.     In  Treatises  by  Various  Authors.      In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.     Price  per  volume,  cloth,  $2.     See 
Stvdenta'  Series  of  Manuals,  page  4. 

We  have  here  the  opinions  of  thirty-three  !  in  the  choice,  arrangement  and  logical  sequence  of 
authors,  in  an  encyclopaedic  form  for  easy  and  ]  the  subjects.  Every  topic,  as  far  as  observed,  is 
ready  reference.  The  three  volumes  embrace  treated  with  a  fulness  of  essential  detail,  which  Is 
every  variety  of  surgical  affections  likely  to  be  I  somewhat  surprising.  Another  characteristic  of  the 
met  with,  the  paragraphs  are  short  and  pithy,  and  |  work  is  the  well-nigh  universal  acceptance  of  mod- 
the  salient  points  and  the  beginnings  or  new  sub-  1  em  and  progressive  views  of  pathology  and  treat- 
jects  are  always  printed  in   extra-heavy  type,  so    ment.    The  entire  work  is  conceived  and  executed 


that  a  person  may  find  whatever  information  he 
may  be  in  need  of  at  a  moment's  glance. — Cin- 
cinnati Lancet-Clinic,  August  21,  1886. 
The  hand  of  Mr.  Treves  is  evident  throughout 


in  a  scientific  spirit.  It  contains  the  bone  and  mar- 
row of  modern  surgery. — AAnals  of  Surgery,  Oct. 
1886. 


BUTLIN,  MEJSRY  T,  F,  R.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 
Diseases    of   the   Tongue.      In  one  12mo.  volume  of  456  pages,  with  8  colored 
plates  and  3  woodcuts.     Cloth,  $3.50.     See  Series  of  Clinical  Mantuds,  page  4. 

The  language  of  the  text  is  clear  and  concise,  j  venientlv  scattered  through  general  works  on  sur- 
The  author  ha.s  aimed  to  state  facts  rather  than  to    gerv  ana  the  practice  of  medicine.    The  physician 
express  opinions,  and  has  compressed  within  the    ancf  surgeon  will  appreciate  its  value  as  an  aid  and 
compass  of  this  small  volume  tne  pathology,  etiol-  i  guide.— P/iy«ici<in  and  Surgeon,  Sept.  1880. 
ogy,  etc.,  of  diseases  of  the  tongue  that  are  incon-  ! 

TREVES,  FREDERICK,  F,  R,  C.  8., 

Surgeon  to  ami  Lecturer  on  Surgery  at  the  London  Hospital. 
Intestinal  Obstruction.     In  one  i)ocket-size  12mo.  volume  of  522  pages,  with  60 
illustrations.  Limf)  cloth,  blue  edges,  $2.00.     .See  Series  of  Clinical  ManwiU,  page  4. 

A  standard  work  on  a  subject  that  has  not  been  I  justice  to  the  author  in  a  few  paragraphs.    Intef 
80  comprehensively  treated  by  any  contemporary;     Ixnal  Obstruction    is  a  work    that    will    ^irove    of 
English   writer.     Its  c         ' 
review  difficult,  since 
nnte  attention,  and 

GOULD,  A.  PEARCE,  M.  S.,  M,  B.,  I.  R.  C.  S„ 

Assistant  Surgeon  to  Muidlenex  HusjhIiU. 

In  one  pocket-size  12mo.  volume  of  689 


y  treated  by  any  contemporary  Ixnal  Uhstructton    is  a  worn    trial    will    nrove    or 

Is  completeness  renders  a  full  equal  value  to  the  practitioner,  the  stuuent,  the 

ice  every  chajiter  deMcrves  mi-  pathologist,  the  physician  and  the  operating  aur- 

it  is  impossible  to  do  thorough  geoD.—Britith  Medual  Journal,  Jan.  Sl,  1886. 


Elements  of  Surgical  Diagnosis.    In  one 

s.     Cloth,  $2.00.     See  Students'  Series  of  Manuals, 


pages. 

PIRRIE'S    PRINCIPLES    AND    PRACTICE  OF 

SURfiERY.  Edited  by  .John  Neii.i.,  M.  I).  In 
one  «vo.  vol.  of  784  pp.  with  .116  lllus.  Cloth,  S;J.76. 
MILLER'S  PRACTICE  OF  HUR(iERY.  Fourth 
and  revised  American  edition.  In  one  large  «vo. 
vol.  of  682  pp.,  with  364  lllustratlonB.    Cloth,  18.76. 


page  4. 


SKEY'S  (il-r.KA  nVK  TUGKRV.  In  one  vol.  8to. 

of'  Mti<.     Cliith,  f3.'26. 

Mil  t   HrR(iKKY.    Fourth 

All'  llnburgh  edition.  In 

ontt  Hv».  v»l.  <j!  Aith  S40  lUuittratlona. 

Cloth,  J3.76. 


22      Lea  Brothers  &  Co.'s  Publications — Siirgery,  Frac,  Disloc. 


SMITH,  STEPHEN,  M.  D., 

Professor  of  Clinical  Surgerij  in  the  University  of  the  City  of  New  York. 

The  Principles  and  Practice  of  Operative  Surgery.  New  (second)  and 
thoroughly  revised  edition.  In  one  very  handsome  octavo  volume  of  892  pages,  with 
1005  illustrations.     Cloth,  $4  00 ;  leather,  $5.00. 


This  excellent  and  very  valuable  book  is  one  of 
the  most  satisfactory  works  on  modern  operative 
surgery  yet  published.  Its  author  and  publisher 
have  spared  no  pains  to  make  it  as  far  as  possible 
an  ideal,  and  their  efforts  have  given  it  a  position 
prominent  among  the  recent  works  in  this  depart- 
ment of  surgery.  The  book  is  a  compendium  for 
the  modern  surgeon.  The  present,  the  only  revised 
edition  since  1879,  presents  many  changes  from 
the  original  manual.  The  volume  is  much  en- 
larged, and  the  text  has  been  thoroughly  revised, 
so  as  to  give  the  most  improved  methods  in  asep- 


tic surgery,  and  the  latest  instruments  known  for 
operative  work.  It  can  be  truly  said  that  as  a  hand- 
book for  the  student,  a  companion  for  the  surgeon, 
and  even  as  a  book  of  reference  for  the  physician 
not  especially  engaged  in  the  practice  or  surgery, 
this  volume  will  long  hold  a  most  conspicuous 
place,  and  seldom  will  its  readers,  no  matter  how 
unusual  the  subject,  consult  its  pages  in  vain.  Its 
compact  form,  excellent  print,  numerous  illustra- 
tions, and  especially  its  decidedly  practical  char- 
acter, all  combine  to  commend  it. — Boston  Medical 
and  Surgical  Journal,  May  10,  1888. 


HOLMES,  TIMOTHY,  M,  A,, 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  Treatise  on  Surgery ;  Its  Principles  and  Practice.  New  American 
from  the  fifth  English  edition,  edited  by  T.  Pickering  Pick,  F.  K.  C.  S.,  Surgeon  and 
Lecturer  on  Surgery  at  St.  George's  Hospital,  London.  In  one  octavo  volume  of  1000 
pages,  with  428  illustrations.     Cloth,  $6 ;  leather,  $7.     Just  ready. 

HOLMES,  TIMOTHY,  M.  A,, 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.  IN  TREATISES  BY 
VARIOUS  AUTHORS.  American  edition,  thoroughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  imperial  octavo  volumes  containing  3137  double- columned  pages,  with 
979  illustrations  on  wood  and  13  lithographic  plates,  beautifully  colored.  Price  per 
set,  cloth,  $18.00;  leather,  $21.00;  half  Russia,  $22.50.     Sold  only  by  subscription. 

8TIMSON,  LEWIS  A.,  B.  A,,  M.  H., 

Surgeon  to  the  Presbyterian  and  Bellevue  Hospitals,  Professor  of  Clinical  Surgery  in  the  Medical 
Faculty  of  Univ.  of  City  of  N.   Y.,  Corresponding  Member  of  the  Societe  de  Chirurgie  of  Paris. 
A  Manual  of  Operative  Surgery.     New  (second)  edition.    In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.     Cloth,  $2.50. 


There  is  always  room  for  a  good  book,  so  that 
while  many  works  on  operative  surgery  must  be 
considered  superfluous,  that  of  Dr.  Stimson  has 
held  its  own.  The  author  knows  the  difficult  art 
of  condensation.  Thus  the  manual  serves  as  a 
work  of  reference,  and  at  the  same  time  as  a 
handy  guide.  It  teaches  what  it  professes,  the 
steps  of  operations.  In  this  edition  Dr.  Stimson 
has  sought  to  indicate  the  changes  that  have  been 


effected  in  operative  methods  and  procedures  by 
the  antiseptic  system,  and  has  added  an  account 
of  many  new  operations  and  variations  in  the 
steps  of  older  operations.  We  do  not  desire  to 
extol  this  manual  above  many  excellent  standard 
British  publications  of  the  same  class,  still  we  be- 
lieve that  it  contains  much  that  is  worthy  of  imi- 
tation.— British  Medical  Journal,  Jan.  22, 1887. 


By  the  same  Author. 
A  Treatise  on  Fractures  and  Dislocations.    In  two  handsome  octavo  vol- 
umes.   Vol.  I.,  Fractures,  582  pages,  360  beautiful  illustrations.    Vol.  II.,  Disloca- 
tions 540  pages,  with  163  illustrations.     Complete  work  just  ready,  cloth,  $5.50 ;  leather, 
$7.50.'    Either  volume  separately,  cloth,  $3.00 ;_  kather,  $4.00. 
The  appearance  of  the  second  volume  marks  the 


completion  of  the  author's  original  plan  of  prepar- 
ing a  work  which  should  present  in  the  fullest 
manner  all  that  is  known  on  the  cognate  subjects 
of  Fractures  and  Dislocations.  The  volume  on 
Fractures  assumed  at  once  the  position  of  authority 
on  the  subject,  and  its  companion  on  Dislocations 
will  no  doubt  be  similarly  received.  The  closing 
volume  of  Dr.  Stimson's  work  exhibits  the  surgery 


of  Dislocations  as  it  is  taught  and  practised  by  the 
most  eminent  surgeons  of  the  present  time.  Con- 
taining the  results  of  such  extended  researches  it 
must  for  a  long  time  be  regarded  as  an  authority 
on  all  subjects  pertaining  to  dislocations.    Every 

Eractitioner  of  surgery  will  feel  it  incumbent  on 
im  to  have  it  for  constant  reference. — Cincinnati 
Medical  News,  May,  1888. 


HAMILTON,  FRANK  H,,  M.  H.,  LL,  !>., 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Seventh  edition 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages  with  379  illustrations.     Cloth,  $5.50 ;  leather,  $6.50 ;  half  Russia,  $7.00. 

This'  book  is  without  a  rival  in  any  language.    It  1  fullj  given.   The  book  is  so  well  known  that  it  does 
is  essentially  a  practical  treatise,  and  it  gathers    not  require  any  lengthened  review.    We  can  only 
within  its  covers  almost  everything  valuable  that    say  that  it  is  still  unapproached  as  a  treatise. — 
has  been  written  about  fractures  and  dislocations.     The  Dublin  Journal  of  Medical  Science,  Feb.  1886. 
The  principles  and  methods  of  treatment  are  very  | 

MARSH,  HOWABHTe,  B.C.  S., 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 
Diseases  of  the  Joints.     In  one  12mo.  volume  of  468  pages,  with  64  woodcuts 
and  a  colored  plate.     Cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  4. 

PICK,  T.  BICKEBING,  F.  B,  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.  In  one  12mo.  volume  of  530  pages,  with  93 
illustrations.     Limp  cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  4. 


Lea  Brothers  &  Co.'s  Publications — otol.,  Ophthal.  23 


BVItimTT,  CSABLJES  H,,  A,  M,,  M,  D,, 

Professor  of  Otology  in  the  PhUadelphia  Polyelinie;  President  of  the  American  Otological  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  New  (second)  edition.  In  one  handsome 
octavo  volume  of  580  pages,  with  107  illustrations.   Qoth,  $4.00 ;  leather,  $5.00. 

We  note  with  pleasure  the  appearance  of  a  second  carried  out,  and  much  new  matter  added  Dr 
edition  of  this  valuable  work.  When  it  first  came  Burnett's  work  must  be  regarded  as  a  very  valual 
out  It  was  accepted  by  the  profession  as  one  of  ble  contribution  to  aural  surgery  not  only  on 
the  standard  works  on  modern  aural  surgery  in  account  of  its  comprehensiveness  but  because  it 
the  English  language;  and  in  his  second  edition  contains  ihe  results  of  the  careful  personal  ob«erv». 
Dr.  Burnett  has  fully  maintained  his  reputation,  tion  and  experience  of  this  eminent  aural  sureeon 
for  the  book  is  replete  with  valuable  information  I  —London  Lancet,  Feb.  21, 1885. 
and  suggestions.    The  revision  has  been  carefully  | 

POLITZEB,  AJDAM, 

Imperial- Royal  Prof,  of  Aural  Therap.  in  the  Univ.  of  Vienna. 
A  Text-Book  of  the  Ear  and  its  Diseases.    Translated,  at  the  Author's  re- 
quest, by  James  Patterson  Cassells,  M.  D.,  M.  K.  C.  S.     In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.     Cloth,  $5.50. 

The  whole  work  can  be  recommended  as  a  reli-  I  the  practitioner  in  his  treatment.— fioston  Medical 
able  guide  to  the  student,  and  an  efficient  aid  to  |  and  Surgical  Journal,  June  7, 1883. 

JTILEJR,  HENnT  E.,  F,  M.  C,  S., 

Senior  AssH  Surgeon,  Royal  Westminster  Ophthah'^r  Hosp. ;  late  Clinical  Aas't,  Moorfields,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handsome 
octavo  volume  of  460  pages,  with  125  woodcuts,  27  colored  plates,  selections  from  the 
Test-types  of  Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test.  Cloth,  $4  50  • 
leather,  $5.50. 

It  presents  to  the  student  concise  descriptions  j  illustrations  are  nearly  all  original.  We  have  ex- 
and  typical  illustrations  of  all  important  eye affee-  amined  this  entire  work  with  great  care,  and  it 
tions,  placed  in  juxtaposition,  so  as  to  be  grasped  represents  the  commonly  accepted  views  of  ad- 
at  a  glance.  Beyond  a  doubt  it  is  the  best  illus-  i  vanced  ophthalmologists.  We  can  most  heartily 
trated  handbook  of  ophthalmic  science  which  has  commend  this  book  to  all  medical  students  prac- 
ever  appeared.    Then,  what  is  still  better,  these  !  titioners  and  specialists.— Z)etroi<  Lancet,  Jan.  '85. 

NETTLESHIP,  EnWARJD,  F.  bTcTs,, 

Ophthalmic  Surg,  and  Lect.  on  Ophth.  Surg,  at  St.  Thomas'  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  New  (third)  edition,  thor- 
oughly revised.  With  a  chapter  on  the  Detection  of  Color-Blindness,  by  William 
Thomson,  M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College.  In  one 
12rao.  volume  of  479  pages,  with  164  illust.,  test-types  and  formulae.  Cloth,  $2.  Just  ready. 
The  extent  of  the  sale  of  this  now  accepted  i  in  the  chapter  devoted  to  operations.  A  very 
authority  has  conclusively  shown  that  its  claim  for  important  partof  the  work  to  general  practitioners 
favor  was  not  an  imaginary  one.  The  introductory  ]  is  that  embraced  in  the  consideration  of  eye  dis- 
chapter  on  optical  outlines  is  a  wonderfully  clear  eases  in  relation  to  general  diseases  and  condi- 
statement  of  the  principles  involved.  The  writer's  |  tions.  The  arrangement  of  the  remedies  employed 
decision  of  character  has  fully  impressed  his  pro-  into  a  formulary  is  adopted,  and  it  contains  much 
duction,  and  this  is  nowhere  more  apparent  tnan  ,  useful  knowledge. — South.  Practitioner,  Dec,  1887. 

NOBItlS,  WM,  F.,  M.  n.,  and  OLIVEB,  CHAS.  A,,  M.  Z>. 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 

A  Text-Book  of  Ophthalmology.  In  one  octavo  volume  of  about  500  pages, 
with  illustrations.     Preparing. 

CARTER,  R.  BRUDENELL^&lFRbST,  W.  ADAMS, 

F.  R.  C.  S,,  F.  R,  a  S., 

Ophthalmic  Surgeon  to  and  Lecturer  on  Oph-  Assistant  Ophthalmic  Surgeon  to  and  Joint 

thalmic    Surgery   at    St.   George's    Hospital,  Lecturer  on   Ophthalmic  Surgery   at    St. 

London.  Oeorge's  Hospital,  London. 

Ophthalmic  Surgery.  In  one  12mo.  volume  of  559  pages,  with  91  woodcuts, 
color  blindness  test,  test-types  and  dots  and  appendix  of  formulae.  Cloth,  $2.25.  See 
Seri^i  of  Clinical  Manuals,  page  4. 

WELLS,  J.  SOELBERG,  F.  R.  C.  S„ 

Professor  of  Ophthalvwlogy  in  Kinq's  College  Hospital,  London,  etc 

A  Treatise  on  Diseases  of  the  Eye.  New  (fifth)  American  from  the  third 
London  edition.     In  one  large  octavo  volume.    Preparing. 

BROWNE,  EnGAR  A,, 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary  and  to  the  Dispensary  for  Skin  Diseases. 
How  to  Use  the  Ophthalmoscope.     Being  Elementary  Instructions  in  Oph- 
thalmoscopy, arranged  for  the  use  of  Students.     In  one  small  royal  12mo.  volume  of  116 
pages,  with  35  illustrations.     Cloth,  $1.00. 

LAURENCE  AND   MOON'S  HANDY    BOOK  OF  1  LAW80N  ON  INJURIES  TO  THE  EYE,  URHIT 
OPHTHALMIC  SURGERY,  for  the  u»e  of  Prac-        AND  EYELIDS:  Their  Immediate  and  RemoU 
titioners.    Second  edition.     In  one  octavo  vol-        Etieots.    8  to.,  404  pp.,  02  lllu«.    Cloth,  tS.SO. 
ame  of  227  pages,  with  06  IlluaU    Cloth,  t2.7S.    I 


24     Lea  Brothers  &  Co.'s  Publications — Urin.  Dis.,  Dentistry,  etc. 


ROBERTS,  WILLIA3I,  31.  2>., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  the  fourth  London  edition.  In  one  hand- 
some octavo  volume  of  609  pages,  with  81  illustrations.     Cloth,  $3.50. 

It  may  be  said  to  be  the  best  book  in  print  on  the  <  giiage  in  its  account  of  the  different  affections. — 
subject  of  which  it  treats. —  The  American  Journal     The  Manchester  Medical  Chronicle,  July,  1886. 
of  the  Medical  Sciences,  Jan.  1886.  The  value  of  this  treatise  as  a  guide  book  to  the 

The  peculiar  value  and  finish  of  the  book  are  in    physician  in  daily  practice  can  hardly  be  over- 
a  measure  derived  from  its  resolute  maintenance     estimated.    That  it  is  fully  up  to  the  level  of  our 


of  a  clinical  and  practical  character.  It  is  an  un 
rivalled  exposition  of  everything  which  relates 
directly  or  indirectly  to  the  diagnosis,  prognosis 
and  treatment  of  urinary  diseases,  and  possesses 
a  completeness  not  found  elsewhere  in  our  Ian- 


present  knowledge  is  a  fact  reflecting  great  credit 
upon  Dr.  Roberts,  who  has  a  wide  reputation  as  a 
busy  practitioner. —  The  Medical  Record,  July  31, 
1886. 


PURDY,   CSARLBS  TF.,  M,  I),,  Chicago. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys. 

volume  of  288  pages,  with  illustrations.     Cloth,  $2. 


In  one  octavo 


The  object  of  this  work  is  to  "furnish  a  system 
atic,  practical  and  concise  description  of  the 
pathology  and  treatment  of  the  chief  organic 
diseases  of  the  kidney  associated  with  albuminu- 
ria, which  shall  represent  the  most  recent  ad- 
vances in  our  knowledge  on  these  subjects  ;"  and 
this  definition  of  the  object  is  a  fair  description  of 
the  book.    The  work  is  a  useful  one,  giving  in  a 


short  space  the  theories,  facts  and  treatments,  and 

going  more  fully  into  their  later  developments, 
n  treatment  the  writer  is  particularly  strong, 
steering  clear  of  generalities,  and  seldom  omit- 
ting, what  text^books  usually  do,  the  unimportant 
items  which  are  all  important  to  the  general  prac- 
titioner.—  The  Manchester  Medical  Chronicle,  Oct., 
188(5. 


MORRIS,  SEWRY,  M.  B.,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 
Surgical  Diseases  of  the  Kidney.      In  one  12mo.  volume  of  554  pages,  with  40 
woodcuts,  and  6  colored  plates.  Limp  cloth,  $2.25.     See  Series  of  Clinical  Manuals,  page  4. 

In  this  manual  we  have  a  distinct  addition  to 
surgical  literature,  which  gives  information  not 
elsewhere  to  be  met  with  in  a  single  work.  Such 
a  book  was  distinctly  required,  and  Mr.  Morris 
has  very  diligently  and  ably  performed  the  task 


he  took  in  hand.  It  is  a  full  and  trustworthy 
book  of  reference,  both  for  students  and  prac- 
titioners in  search  of  guidance.  The  illustrations 
in  the  text  and  the  chromo-lithographs  are  beau- 
tifully executed. —  The  London  LajiceJ,  Feb.  26, 1886. 


See  Series 


LUCAS,  CLBMBNT,  M.  B.,  B.  S.,  F.  R.  C.  S., 

Senior  Assistant  Surgeon  to  Ghiy^s  Hospital,  London. 
Diseases   of  the   Urethra.      In  one   12mo.  volume.     Preparing, 
of  Clinical  Manuals,  page  4. 

TSOMFSOJS,  SIR  SFJVRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.     In  one  Svo.  volume  of  203  pp.,  with  25  illustrations.     Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulse.     From  the  third  English  edition.     In  one  octavo  volume  of  359 
pages,  with  47  cuts  and  3  plates.    Cloth,  $3.50. 

TSF  AMERICAN  SYSTEM  OF  DENTtSTRY. 

In  Treatises  by  Various  Authors.  Edited  by  Wilbur  F.  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  con- 
taining 3160  pages,  with  1863  illustrations  and  9  full  page  plates.  Per  volume,  cloth,  $6 ; 
leather,  $7  ;  half  Morocco,  gilt  top,  $8.  The  complete  work  is  now  ready.  For  sale  by 
subscription  only. 


As  an  encyclopaedia  of  Dentistry  it  has  no  su- 
perior. It  should  form  a  part  of  every  dentist's 
library,  as  the  information  it  contains  is  of  the 
greatest  value  to  all  engaged  in  the  practice  of 
dentistry. — American  .Tour.  Dent.  Set.,  Sept.,  1886. 

A  grand  system,  big  enough  and  good  enough' 
and  handsome  enough  for  a  monument  (which i 


doubtless  it  is),  to  mark  an  epoch  in  the  history  ol 
dentistry.  Dentists  will  be  satisfied  with  it  and 
proud  of  it — they  must.  It  is  sure  to  be  precisely 
what  the  student  needs  to  put  him  and  keep  him 
in  the  right  track,  while  tne  profession  at  large 
will  receive  incalculable  benent  from  it. — Odonto- 
graphic  Journal,  Jan.  1887. 


COLEMAN,  A.,  L.  R.  C.  F.,  F.  R.  C.  S.,  Exam.  L.  I).  S., 

Senior  Dent.  Surg,  and  Led.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hosp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellvpagen,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  in  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 


It  should  be  in  the  possession  of  every  practi- 
tioner in  this  country.  The  part  devoted  to  first 
and  second  dentition  and  irregularities  in  the  per- 
manent teeth  is  fully  worth  the  price.  In  fact, 
price  should  not  be  considered  in  purchasing  such 
a  work.  If  the  money  put  into  some  of  our  so- 
called  standard  text-hooks  could  be  converted  into 
such  publications  as  this,  much  good  would  result. 
— Southern  Dental  Journal,  May,  1882. 


The  author  brings  to  his  task  a  large  experience 
acquired  under  the  most  favorable  circumstances. 
There  have  been  added  to  the  volume  a  hundred 
pages  by  the  American  editor,  embodying  the 
views  of  the  leading  home  teachers  in  dental  sur- 
gery. The  work,  therefore,  may  be  regarded  as 
strictly  abreast  of  the  times,  and  as  a  very  high 
authority  on  the  subjects  of  which  it  treats. — 
American  Practitioner,  July,  1882. 


BA8HAM    ON    RENAL    DISEASES:   A   Clinical 
Guide  to  their  Diagnosis  and   Treatment.    In 


one  12mo.  vol.  of  304  pages,  with  21  lllastrations. 
Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Venereal,  Impotence.  25 

GBOSS,  SAMUEL  W,,  A.  M,,  M.  D.,  ii.  2>., 

Profeesor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College  of  Phila, 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  New  (third)  edition,  thoroughly  revised.  In  one  very 
handsome  octavo  volume  of  163  pages,  with  16  illustrations.     Cloth,  $1.50. 

It  must  be  gratifying  to  both  author  and  pub-  i  This  now  classical  work  on  the  subject  of  impo- 
lishers  that  large  first  and  second  editions  of  this  tence  and  sterility  in  the  male  needs  no  ext«ncled 
little  work  were  so  soon  exhausted,  while  the  fact  review,  for  it  is  already  well  known  to  the  pro- 
that  it  has  been  translated  into  Russian  may  indi-  fession.  Dr.  Gross  has  by  his  tireless  labor  done 
cate  that  it  filled  a  void  even  in  foreign  literature,  more  towards  clearing  up  the  diagnosis  and  treat- 
His  is  a  careful  and  physiological  study  of  the  mentof  these  obscure  cases  than  any  other  Ameri- 
sexual  act,  so  far  as  concerns  the  male,  and  all  can  physician.  The  fact  that  this  book  has  rapidly 
his  conclusions  are  scientifically  reached.  The  run  through  two  large  editions,  and  that  the  author 
book  has  a  place  by  itself  in  our  literature,  and  is  now  forced  to  issue  a  third,  is  good  and  sufficient 
furnishes  a  large  fund  of  information  concerning  evidence  of  its  exceUence.— Atlanta  Medical  and 
Important  matters  that  are  too  often  passed  over  Surgical  Journal,  April,  1888. 
in  silence. — The  Medical  Press,  June,  1887.  i 


TAYLOR,  B.  W,,  A.  M.,  M,  D., 


Surgeon  to  Charity  Hospital,  New  York,  Prof,  of  Venereal  and  Skin  Diseases  in  the  University  of 
Vermont,  Pres.  of  the  Am.  Dermatological  Ass'n. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  Being  the  sixth  edition  of  Bumstead 
and  Taylor.  Entirely  rewritten  by  Dr.  Taylor.  Large  and  handsome  8vo.  volume, 
about  900  pages,  with  about  150  engravings,  a?  well  as  numerous  chromo-lithographs. 
Preparing. 

A  few  notices  of  the  previous  edition  are  appended. 

It  is  a  splendid  record  of  honest  labor,  wide  '  known  that  it  would  be  superfluous  here  to  pass  in 
research,  just  comparison,  careful  scrutiny  and  review  its  general  or  special  points  of  excellence, 
original  experience,  which  will  always  be  held  as  The  verdict  of  the  profession  has  been  passed;  It 
»  high  credit  to  American  medical  literature.  This  has  been  accepted  as  the  most  thorough  and  cora- 
ls not  only  the  best  work  in  the  English  language  plete  exposition  of  the  pathology  and  treatment  of 
UDon  the  subjects  of  which  it  treats,  but  also  one  venereal  diseases  in  the  language.  Admirable  as  a 
wnich  has  no  equal  in  other  tongues  for  its  clear,  model  of  clear  description,  an  exponent  of  sound 
comprehensive  and  practical  handling  of  its  pathological  doctrine,  and  a  guide  for  rational  and 
themes. — Am.  Jour,  of  the  Med.  Sciences,  Jan,  1884.    j  successful  treatment,  it  is  an  ornament  to  the  medi- 

It  is  certainly  the  best  single  treatise  on  vene-  cal  literature  of  this  country.  The  additions  made 
real  in  our  own,  and  probably  the  best  in  any  Ian- J  to  the  present  edition  are  eminently  judicious, 
guage. — Boston  Med.  and  Surg.  Journal,  April  3, 1884.  j  from  the  standpointof  practical  utility. — Journal  of 

The  character  of  this  standard  work  is  so  well  i  Cutaneous  and  Venereal  Diseases,  Jan.  1884. 

COBKIL,  F., 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Loureine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  oy  the  Author,  and  translated  with  notes  and  additions  by  J.  Henky  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  William  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  of  Pennsylvania.  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.  Cloth,  $3.75. 
The  anatomy,  the  histolo^,  the  pathology  and  1 
the  clinical  features  of  syphilis  are  represented  in 
this  work  in  their  best,  most  practical  and  most 
initructive  form,  and  no  one  will  rise  from  its    tioner,  Jan.  1882 

HUTCHINSON,  JONATHAN,  JF.  B,  S.,  F,  B.  C.  S., 

Consulting  Surgeon  to  the  London  Hospital. 

Syphilis.  In  one  12mo.  volume  of  542  pages,  with  8  chromo-lithographs.  Cloth, 
$2.25.     See  Series  of  Clinical  ManruUa,  page  4. 

Those  who  have  seen  most  of  the  disease  and  and  power  of  observation,  but  of  his  patience  and 
those  who  have  felt  the  real  difficulties  of  diagno-  ;  assiduity  in  taking  notes  of  his  ca.sea  and  keep- 
sis  and  treatment  will  most  highly  appreciate  the  i  ing  them  in  a  form  available  for  such  excellent 
facts  and  sugge-tions  which  abound  in  these  !  use  as  he  has  put  them  to  in  this  volume.— London 
pages.  It  is  a  worthy  and  valuable  record,  not  ^  Medical  iJecord,  Nov.  12,  1887. 
only  of  Mr.  Hutchinson's  very  large  experience  | 


The  anatomy,  the  histolo^,  the  pathology  and  1  perusal  without  the  feeling  that  his  grasp  of  the 
the  clinical  features  of  syphilis  are  represented  in  wide  and  important  subject  on  which  it  treats  is 
this  work  in  their  best,  most  practical  and   most    a  stronger  and  surer   one. — The  London  Practt- 


GBOSS,  S.  n.,  M,  JD,,  LL.  2>.,  D.  C.  L,,  etc, 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Tliird 
edition,  thoroughly  revised  by  Samuel  W.  Gkoss,  M.  D.  In  one  octavo  volume  of  674 
pages,  with  170  illustrations.     Cloth,  $4.50. 

CULLEBIEB,  A,,  &  BUMSTEAD,  F,  J,,  M,JD„  LL.U., 

Surgeon  to  the  UOpital  du  Midi.  Late  Professor  oj  Vey\«real  IHseaae*  in  the  College  of  Physiewnt 

niui  Surgeong,  Aeio  Yirrlc 

An  Atlas  of  Venereal  Diseases.  Tmnslatc<l  and  e<lited  by  Free.man  J.  Bum- 
OTEAD,  M.  D.  In  one  imjterial  4to.  volume  of  328  pages,  double-columns,  with  26  plateu, 
containing  al>out  150  figures,  beautifully  colored,  many  of  them  the  size  of  life.  Strongly 
bound  in  cloth,  $17.00.    A  specimen  of  the  plates  and  text  sent  by  mail,  on  reieipt  of  25  ct«. 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS    FORMS    OK     LOCAL     DISEA.SE     AKKKCTING 

DISORDERS.  lnone8vovol.of470p.CI(.lh,«:i.;«.    PRINCIPALLY    THE   ORGANS    OF    GENERA- 

LEE'8   LECTURES  ON  SYPHILIS  AND  SUME,TION.    In  one  8to.  vol.  of  246  page».    Cloth.  |2.2«. 


26 


Lea  Brothers  &  Co.  s  Publications — Venereal,  Skin. 


TAYLOR,  ROBERT  W,,  A.M.,  M.I)., 

Surgeon  lo  Charity  Hospital,  New  York,  and  to  the  Department  of  Venereal  and  Skin  Diseases  of 
the  A'eio  Vork  Hospital. 

A  Clinical  Atlas  of  Venereal  and  Skin  Diseases:  Including  Diagnosis, 
Prognosis  and  Treatment.  In  eight  large  folio  parts,  measuring  14  x  18  inches,  and 
comprising  58  beautifully-colored  plates  with  192  figures,  and  400  pages  of  text  with  65 
engravings.  Price  per  part,  $2.50.  Parts  I.  and  II.  are  just  ready.  For  sale  by  sviscHp- 
tion  only.  Specimen  plates  sent  on  receipt  of  10  cents.  A  full  prospectus  is  now  ready 
for  distribution  on  application. 


This  magnificent  Clinical  Atlas,  we  do  not  hesi- 
tate to  say,  will  he  regarded  as  one  of  the  most 
valuable  and  handsome  contributions  to  the  medi- 
cal literature  of  the  age.  As  its  name  implies,  the 
Clinical  Atlas  is  intended  as  a  working  guide  for 
any  practitioner  who  chooses  to  deal  with  the  wide- 
spread class  of  chronic  diseases  included  in  its 
title.    For  the  adequate  accomplishment  of   its 

fiurpose  such  a  work  must  comprise  pictures,  life- 
ike  in  form  and  color,  of  a  size  as  large  as  is  com- 
patible with  convenience,  together  with  a  descrip- 
tive, clinical  and  didactic  text.  The  entire  litera- 
ture of  the  subjects  has  been  searched  for  its  best 
illustrations,  and  selections  made  with  proper 
permission  of  living  authors.  These  have  been 
complemented  by  numerous  reproductions  from  a 
collection  of  original  paintings  from  life,  gathered 
by  the  author  during  many  years  of  practice.  The 
text  has  been  designed  to  furnish  the  practitioner 
with  clear  and  explicit  directions  for  the  proper 
management  of  his  cases,  and  at  the  same  time  to 
stimulate  the  interest  of  those  who  may  wish  to 
devote  their  life-work  to  these  subjects.  A  full 
statement  of  the  clinical  history,  varying  features, 
etiology,  diagnosis,  and  prognosis  has  therefore 
been  followed  by  definite  and  complete  thera- 
peutical information.  In  their  respective  spheres 
the  author  and  publishers  have  left  nothing  undone 
to  make  the   Clinical  Atlas  a  work  which  will  be 


recognized  as  a  standard  authority  on  its  subjects. 
The  strong  faith  of  its  publishers  in  the  merit 
and  wide  appreciation  which  they  must  feel 
assured  awaits  the  Clinical  Atlas  at  the  hands  of  a 
discriminating  medical  public  is  evidenced  by 
the  very  moderate  figure  at  which  it  is  supplied,  a 
figure  so  much  below  that  customarily  charged 
for  works  of  this  class  that  only  the  widest  dis- 
semination can  possibly  bring  them  a  fair  return 
for  their  evidently  lavish  outlay. — Southern  Prae^ 
<t<ioner,  Sept.,  1888. 

Viewing  this  collection  as  a  whole  it  may  be  said 
that  it  is  difficult  to  overestimate  its  clinical  value 
to  the  practitioner  and  diagnostician.  A  careful 
study  of  even  the  smallest  of  these  portraits  of 
disease  will  repay  the  student.  Their  practical 
value  in  teaching  is  exactly  proportioned  to  their 
faithfulness  to  fact.  In  the  important  matters  of 
etiology  and  treatment,  the  author  is  as  lucid  and 
practical  as  might  be  anticipated  from  one  of  his 
experience  and  previous  contributions  to  derma- 
tological  literature.  Dr.  Taylor's  Atlas  is  to  be 
warmly  commended  to  the  expert,  the  general 
practitioner,  and  the  student,  as  an  Invaluable  aid 
in  acquiring  a  knowledge  of  the  subjects  illus- 
trated, combining  in  a  high  degree  the  advantages 
of  a  sound  text- book,  with  the  special  assistance 
of  colored  illustrations. —  The  American  Journal  of 
the  Medical  Sciences,  April,  1889. 


SYDE,  J.  NEVIJSrS,  A.  M.,  M.  D., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Rush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  and 
Practitioners.  New  (second)  edition.  In  one  handsome  octavo  volume  of  676  pages, 
with  2  colored  plates  and  85  beautiful  and  elaborate  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50.     Just  ready. 


We  can  heartily  commend  it,  not  only  as  an 
admirable  text-book  for  teacher  and  student,  but 
in  its  clear  and  comprehensive  rules  for  diagnosis, 
its  sound  and  independent  doctrines  in  pathology, 
and  its  minute  and  judicious  directions  for  the 
treatment  of  disease,  as  a  most  satisfactory  and 
complete  practical  guide  for  the  physician. — Ameri- 
can Journal  of  the  Medical  Sciences,  July,  1888. 

A  useful  glossary  descriptive  of  terms  is  given. 
The  descriptive  portions  of  this  work  are  plain 
and  easily  understood,  and  above  all  are  very 
accurate.  The  therapeutical  part  is  abundantly 
supplied  with  excellent  recommendations.  The 
picture  part  is  well  done.  The  value  of  the  work 
to  practitioners  is  great  because  of  the  excellence 
of  the  descriptions,  the  suggestiveness  of  the 
advice,  and  the  correctness  of  the  details  and  the 
principles  of  therapeutics  impressed  upon  the 
reader. —  Virginia  Med,  Monthly,  May,  1888. 


The  second  edition  of  his  treatise  is  like  his 
clinical  instruction,  admirably  arranged,  attractive 
in  diction,  and  strikingly  practical  throughout. 
The  chapter  on  general  sym  ptomatology  is  a  model 
in  its  way ;  no  clearer  description  of  the  various 

Erimary  and  consecutive  lesions  of  the  skin  is  to 
e  met  with  anywhere.  Those  on  general  diagno- 
sis and  therapeutics  are  also  worthy  of  careful 
study.  Dr.  Hyde  has  shown  himself  a  compre- 
hensive reader  of  the  latest  literature,  and  has  in- 
corporated into  his  book  all  the  best  of  that  which 
the  past  years  have  brought  forth.  The  prescrip- 
tions and  formulse  are  given  in  both  common  and 
metric  systems.  Text  and  illustrations  are  (food, 
and  colored  plates  of  rare  cases  lend  additional 
attractions.  Altogether  it  is  a  work  exactly  fitted 
to  the  needs  of  a  general  practitioner,  and  no  one 
will  make  a  mistake  in  purchasing  ii.— Medical 
Press  of  Western  New  York,  June,  1888. 


EOX,  T.,  M.  J).,  F.R.  C.  P.,  and  FOX,  T.  C,  B.A.,  M.R.  C.8., 

Physician  to  the  Department  for  Skin  Diseases,  Physician  for  Diseases  of  the  Skin  to  the 

University  College  Hospital,  London.  Westminster  Hospital,  London. 

An  Epitome  of  Skin  Diseases.  With  Formulae.  For  Students  and  Prac- 
titioners. Third  edition,  revised  and  enlarged.  In  one  very  handsome  12mo.  volume 
of  238  pages.     Cloth,  $1.25. 


The  third  edition  of  this  convenient  handbook 
calls  for  notice  owing  to  the  revision  and  expansion 
which  it  has  undergone.  The  arrangement  of  skin 
diseases  in  alphabetical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 
to  students  but  also  to  practitioners  who  require  a 
compendious  summary  of  the  present  state  of 
dermatolo^. — British  Medical  Journal,  July  2, 1883. 

We  cordially  recommend  Fox's  Epitometo  those 
whose  time  is  limited  and  who  wish    a  handy 


manual  to  lie  upon  the  table  for  instant  reference. 
Its  alphabetical  arrangement  is  suited  to  this  use, 
for  all  one  has  to  know  is  the  name  of  the  disease, 
and  here  are  its  de.scription  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  hsis  been  very  carefully 
revised  and  a  number  of  new  diseases  are  de- 
scribed, while  most  of  the  recent  additions  to 
dermal  therapeutics  find  mention,  and  the  formu- 
lary at  the  end  of  the  book  has  been  considerably 
augmented. —  TTie  Medical  News,  December,  1883. 


WILSON,  ERASMUS,  F.  R.  S. 

The  Student's  Book  of  Cutaneous  Medicine  and  Diseases  of  the  Skin. 
In  one  handsome  small  octavo  volume  of  535  pages.     Cloth,  $3.50. 


HILLIER'S  HANDBOOK  OF  SKIN  DISEASES; 
for  Students  and  Practitioners.    Second  Ameri- 


can edition. 
with  plates. 


In  one  12mo.  volume  of  353  pages, 

Cloth,  S2.25. 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Womeu.  27 

The  American  Systems  of  Gynecology  and  Obstetrics. 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors.  Gynecology  edited  by  Matthew  D.  Majsn,  A.  M.,  M.  D.,  Professor  of  Obstetrics 
and  Gynecology  in  the  Medical  Department  of  the  University  of  Buffalo;  and  Obstet- 
rics edited  by  Barton  Cooke  Hirst,  M.  D.,  Associate  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania,  Philadelphia.  In  four  very  handsome  octavo  volumes  of 
about  900  pages  each,  fully  illustrated  by  wood  engravings  and  colored  plates.  Volumes 
I.  and  II.  of  the  Gynecology,  and  Volume  I.  of  the  Obstetrics  containing  2764  pages, 
871  engravings  and  8  colored  plates,  are  nov  ready.  Volume  II.  of  the  Obstetrics, 
completing  the  work,  will  be  ready  in  May.  Per  volume:  Cloth,  $5.00;  leather,  $6.00; 
half  Russia,  $7.00.  For  sale  by  subscription  only.  Address  the  Publishers.  Full  descrip- 
tive circular  free  on  application. 

LIST  OF  CONTRIBUTORS. 


WILLIAM  H.  BAKER,  M.  D., 
ROBERT  BATTEY,  M.  D., 
SAMUEL  0.  BUSEY,  M.  D., 
JAMES  C.  CAMERON,  M.  D., 
HENRY  C.  COE,  A.  M.,  M.  D., 
EDWARD  P.  DAVIS,  M.  D., 
G.  E.  De  SCHWEINITZ,  M.  D., 
E.  0.  DUDLEY,  A.  B.,  M.  D., 
B.  McE.  EMMET,  M.  D., 
GEORGE  J.  ENGELMANN,  M.  D., 
HENRY  J.  GAHRIGUES,  A.  M..  M.  D., 
WILLIAM  GOODELL,  A.  M.,  M.  D., 
EGBERT  H.  GRANDIN,  A.  M.,  M.  D., 
SAMUEL  W.  GROSS,  M.  D., 
ROBERT  P.  HARRIS,  M.  D., 
GEORGE  T.  HARRISON,  M.  D., 
BARTON  C.  HIRST,  M.  D. 
STEPHEN  Y.  HOWELL,  M.  D., 
A.  REEVES  JACKSON,  A.  M.,  M.  D., 
W.  W.  JAGGARD,  M.  D., 
EDWARD  W.  JENKS,  M.  D.,  LL.  D., 
HOWARD  A.  KELLY,  M.  D., 
This  is  a  very  valuable  contribution  to  the  liter-  | 


CHARLES  CARROLL  LEE,  M.  D., 
WILLIAM  T.  LUSK,  M.  D.,  LL.  D., 
J.  HENDRIE  LLOYD,  M.  D  , 
MATTHEW  D.  MANN,  A.  M.,  M.  D., 
H.   NEWELL   MARTIN,  F.  R.  S.,  M.  D., 

D.Sc,  M.A., 
RICHARD  B.  MAURY,  M.  D., 
C.  D.  PALMER,  M.  D., 
ROSWELL  PARK,  M.  D., 
THEOPHILUS  PARVIN,  M.  D.,  LL.  D., 
R.  A.  F.  PENROSE,  M.  D.,  LL.  D., 
THADDEUS  A.  REAMY,  A.  M.,  M.  ID., 
J.  C.  REEVE,  M.  D., 
A.  D.  ROCKWELL,  A.  M.,  M.  D., 
ALEXANDER  J.  C.  SKENE,  M.  D., 
J.  LEWIS  SMITH,  M.  D., 
STEPHEN  SMITH,  M.  D., 
R.  STANSBURY   SUTTON,  A.  M.,  M.  D., 

LL.  D., 
T.  GAILLARD  THOMAS,  M.  D.,  LL.  D., 
ELY  VAN  DE  WARKER,  M.  D., 
W.  GILL  WYLIE,  M.  D. 
In  our  notice  of  the  "System  of  Practical  Medi- 


ature  of  obstetrics.    The  editors,  contributors  and  :  cine  by  American  Authors,"  we  made  the  follow 


publishers  are  entitled  to  most  hearty  congratu- 
lations for  the  complete  kind  of  work  that  lias 
appeared. —  The  Obstetric  Oazette,  August,  1888. 

This,  the  companion  work  to  the  System  of 
Gynecology  by  American  Author,*,  equals  it  in  the 
excellence  of  the  subject-matter  and  the  perfec- 
tion of  the  publishers'  art.  .\s  a  treatise  for  the 
use  of  the  practitioner  the  work  will  be  found  to 
represent  admirably  the  obstetric  science  of  the 
day  as  exemplified  in  American  practice.— TVie 
Medical  Neirs,  August  25,  1888. 

There  can  be  but  little  doubt  that  this  work  will 
find  the  same  fayor  with  the  profession  that  has 
been  accorded  to  the  "System  of  Medicine  by 
American  Authors,"  and  the  "Sj;stem  of  Gynecol- 
ogy byAmerican  Authors."  One  is  at  a  loss  to  know 
what  to  say  of  this  volume,  for  fear  that  just  and 
merited  praise  maybe  mistaken  for  flattery.  The 
subjects  of  some  of  the  papers  are  di.scussed  in 
various  works  on  obstetric.",  though  not  to  the  full 
extent  that  is  found  in  this  volume.  The  papers 
of  Drs.  Engelmann,  Martin,  Hir.'it,  Jaggard  and 
Reeve  are  incomparably  beyond  anything  that  can 
be  found  in  obstetrical  works.  Certainly  the  Edi- 
tor may  be  congratulated  for  having  made  such  a 
wise  selection  of  his  contributors. — Journal  of  ilie 
American  Medical  A nsoeiation,  Sept.  8,  1888. 


ing  statement:— "It  is  a  work  of  which  the  pro- 
fession in  this  country  can  feel  proud.  Written 
exclusively  by  American  physicians  who  *re  ac- 
quainted with  all  the  varieties  of  climate  in  the 
United  States,  the  character  of  the  soil,  the  man- 
ners and  customs  of  the  people,  etc.,  it  is  pecul- 
iarly adapted  to  the  wants  of  American  practition- 
ers of  medicine,  and  it  seems  to  us  that  every  one 
of  them  would  desire  to  have  it."  Every  word 
thus  expressed  in  regard  to  the  "American  Sys- 
tem of  Practical  Medicine"  is  applicable  to  the 
"System  of  Gynecology  by  American  Authors," 
which  we  desire  now  to  bring  to  the  attention  of 
our  readers.  It,  like  the  other,  has  been  written 
exclusively  by  American  physicians  who  are 
acquainted  witn  all  the  characteristic,"  of  American 
people,  who  are  well  informed  in  regard  to  the 
peculiarities  of  American  women,  their  manners, 
customs,  modes  of  living,  etc.  As  every  practis- 
ing physician  is  called  upon  to  treat  diseases  of 
females,  and  as  they  constitute  a  class  to  which 
the  familly  physician  must  give  attention,  and 
cannot  pass  over  to  a  specialist,  we  do  not  know  of 
a  work  in  any  department  of  medicine  that  we 
should  so  strongly  recommend  medical  men  gen- 
erally purchasing. — Oincinnati  Med.  Xeus,  July,l887. 


THOMAS,  T.  GAILLARD,  M,  !>., 

Professor  of  Diseases  of  Women  in  the  College  of  Physicians  atid  Surgeons,  N.  Y. 

A  Practical  Treatise  on  the  Diseases  of  Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  liandsome  octavo  volume  of  810  pages,  with  266 
illustrations.  Clot'i,  $5.00 ;  leather,  $6.00 ;  very  hand.some  half  RiL-wia,  raise<l  bands,  $6.60. 
That  the  previous  editions  of  the  treatise  of  Dr.  I  rician  and  gynrecologist  asasafe  guide  to  jiraotlce. 
Thomas  were  thought  worthy  of  translation  Into  i  No  small  number  of  additions  have  beeo  made  U> 
German,  French,  Italian  and  Spanish,  is  enough  '  the  present  edition  to  make  it  correspond  *o  re- 
to  give  it  the  stam)>  of  genuine  merit.  At  home  It  I  cent  improvements  In  treBtmenl.— /'nrtrtf  Meaieal 
has  made  its  way  into  the  library  of  every  obstet-  I  and  Surqirnl  Journal,  Jan.  1H81. 

EL>IS,  ARTHUR  W.,  3L  I).,  Lond,,  F.R.  C'.i^,  M.R,  C,S., 

Assvit.  Obstetric  Phyncian  to  Miiiiilesex  Hospital,  late  Physician  to  British  Lying-in  Ilosjninl. 
The  Diseases  of  Women.     Including   their    Patholog)-,  Causiition,  SympU)m8, 
Diagnosis  and  Treatment.     A  Manual  for  Students  and  rractitioners.     In  one  handsome 
octavo  volume  of  o76  pages,  with  148  illustrations.     Clotli,  $:?.0();  leather.  $4.00 
It   Is  a  pleasure  to  read   a  book  so  thoroughly    are  among  the  more  mn.v    -    ■■'••'  ■■ 
good  as  this  one.    The  special  qualities  which  are     ment,  and  yet  very  little 
consi)lcuous  are    thoroughness   In    covering    the  i  many  of  thw  (ext-lHwiUx, 

whole   ground,  clearness  of  description  an<I  con-     wan    '      -    '     '  ' 

cisenes,"  of  statement.     Another  marked  feature  of    ge' 
the   book  is  the  attention    paid  to  the   details   of    pit  i 
many  minor  surgical  operations  and  procedure.",    will  mui  iinm.v  u-.-un  .i......  ...  - 

as,  for   instance,  the   use  of  tents,  application   of    Med.  atid  liurg.  Joum.,  March  U,  1- 
leeches,  and  use  of  hot  water  injections.    These  i 


do  of  tre«t- 
,1  them  In 
.  one  to  b« 

•  om- 

,  too, 

:  uston 


28         Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women,  Midwfy. 
EMMET,  THOMAS  AI>I)IS,  M,  !>.,  LL,  J>.,  ~ 

Surgeon  to  the  Wo7nan's  Hospital,  J\'ew  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  New  (third)  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  $5 ;  leather,  $6; 
very  handsome  half  Russia,  raised  bands,  $6.50. 

We  are  in  doubt  whether  to  congratulate  the 
author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  worli. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  himself 


nal.  May  16, 1885. 

The  time  has  passed  when  Emmet's  Gfyncecology 

was  to  be  regarded  as  a  book  for  a  single  country 

or  for  a  single  generation.    It  tias  always  been  hie . 

aim  to  popularize  gyneecology,  to  bring  it  within 

as  a  bold  and  successful  operator,  and  who  has  I  easy  reach  of  the  general  practitioner.    The  orig- 


devoted  so  much  attention  to  the  specialty,  we  I  inaiity  of  the  ideas  compels  our  admiration  and 
feel  sure  the  profession  will  not  fail  to  appreciate  i  respect.  We  may  well  take  an  honest  pride  in 
the  privilege  thus  offered  them  of  perusing  the  j  Dr.  Emmet's  work  and  feel  that  his  book  can 
▼lews  and  practice  of  the  author.  His  earnestness  I  hold  its  own  against  the  criticism  of  two  conti- 
of  purpose  and  conscientiousness  are  manifest,  nents.  It  represents  all  that  is  most  earnest  and 
He  gives  not  only  his  individual  experience  but  I  most  thoughtful  in  American  gyneecology. — Amer- 
endeavors  to  represent  the  actual  state  of  gynse-  I  ican  Journal  of  Obstetrics,  May,  1885. 
cological   science  and  art. — British  Medical  Jour-  \ 

TAIT,  LAWSOJSr,  F,  B,  C,  S,, 

Fellow  of  the  Roijal  Medico- Chirurgieal  Society  of  London,  Honorary  Member  of  the  Boston  Gyne- 
cological Society ,  Surgeon  to  the  Birminghnm  and  Midland  Hospital  for  Women. 

Diseases  of  Women  and  Abdominal  Surgery.  In  one  very  handsome 
octavo  volume  of  600  pages,  fully  illustrated.     In  press. 

DAVENPORT,  F,   H,,  M,  J>., 

Assistant  in  Gyneecology  in  the  Medical  Department  of  Harvard  University,  Boston. 

Diseases  of  Women,  a  Manual  of  Non-Surgical  Gynsecology.  De- 
signed especially  for  the  Use  of  Students  and  General  Practitioners.  In  one  handsome 
12mo.  volume  with  many  illustrations.     Shortly. 

DUNCAN,  J.  MATTHEWS,  M.D.,  LL,  D.,  F.  M,  S,  E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.     In  one  handsome  octavo  volume  of  175  pages.     Cloth,  $1.50. 


Thev  are  in  every  way  worthy  of  their  author ; 
indeed,  we  look  upon  them  as  among  the  most 
valuable  of  his  contributions.  They  are  all  upon 
matters  of  great  interest  to  the  general  practitioner. 
Some  of  them  deal  with  subjects  that  are  not,  as  a 


rule,  adequately  handled  in  the  text-books;  others 
of  them,  while  bearing  upon  topics  that  are  usually 
treated  of  at  length  in  such  works,  yet  bear  such  a 
Btamp  of  individuality  that  they  deserve  to  be 
widely  read. — N.  Y.  Medical  Journal,  March,  1880. 


MAT,    CHARLES  H,,  M,  D,, 

Late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York. 

A  Manual  of  the  Diseases  of  Women.  Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynsecologv.  In  one  12mo.  volume  of  342  pages, 
aoth,  $1.75. 

HODGE,  HUGHL,,  M,  D,, 

Emieritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 
On  Diseases  Peculiar  to  Woraen;  Including  Displacements  of  the  Uterus. 
Second  edition,  revised  and  enlarged.     In  one  beautifully  printed  octavo  volume  of  519 
pages,  with  original  illustrations.     Cloth,  $4.50. 

By  the  Same  Author. 

The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  numerous  wood- 
cuts. In  one  large  quarto  volume  of  542  double-columned  pages.  Strongly  bound  in 
cloth,  $14.00.  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address, 
free  by  mail,  on  receipt  of  six  cents  in  postage  stamps. 

RAMSBOTHAM,  FRANCIS  H,,  M,  D, 

The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery: 

In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly  revised 
by  the  Author.  With  additions  by  W.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.     Strongly  bound  in  leather,  with  raised  bands,  $7. 

WINCKEL,  F,  ~        " 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.  Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  by  J.  R.  Chadvs^ick,  M.  D.    Octavo  484  pages.    Cloth,  $4.00. 

WEST,  CHARLES,  M,  D. 

Lectures  on  the  Diseases  of  Women.  Third  American  from  the  third  Lon- 
don edition.     In  one  octavo  volume  of  543  pages.     Cloth,  $3.75 ;  leather,  $4.75. 

ASHWELL'S  PRACTICAL  TREATisE~OirTH¥l  AND  OTHER  DISEASES  PECULIAR  TO  WO- 
DISEASES  PECULIAR  TO  WOMEN.  Third  MEN.  In  one  8vo.  vol.  of  464  pages.  Cloth,  $2.50. 
American  from  the  third  and  revised  London  i  MEIG.S  ON  THE  NATURE,  SIGNS  AND  TRBAT- 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth,  $3.50.     I      MBNT  OF  CHILDBED  FEVER.    In  one  8yo. 

CHURCHILL  ON    THE    PUERPERAL  FEVER  |      volume  of  346  pages.    Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Midwifery. 


29 


rABVIIf,  TSBOPSILVS,  M,  JD.,  ii.  !>., 

Prof,  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  Jefferson  Med.  Coll.,  Phila. 

The  Science  and  Art  of  Obstetrics.    In  one  handsome  8vo.  volume  of  697 
pages,  with  214  engravings  and  a  colored  plate.     Cloth,  $4.25 ;  leather,  $5.25. 

It  is  a  ripe  harvest  that  Dr.  Parvin  offers  to  his  ;  favorable  for  an  agreeable  unfolding  of  the  science 

readers.    There  is  no  book  that  can  be  more  safely  and  art  of  obstetrics.    This  new  book  is  the  easy 

recommended  to  the  student  or  that  can  be  turned  superior  of  any  single  work  among  its  predeces- 

to  in  moments  of  doubt  with  greater  assurance  of  sors  for  the  student  or  practitioner  seeking  the 

aid,  as  it  is  a  liberal  digest  of  safe  counsel  that  has  best  thought  of  the  day  in  this    department   of 

been  patiently  gathered. —  The  American  Journal  medicine. — The  American  Practitioner  and  News, 

of  the  Medical  Sciences,  July,  1887.  April  2,  1887. 

There  is  not  in  the  language  a  treatise  on  the        This  treatise  may  be  defined  as  exact,  concise 

subject  which    so    completely    and    intelligently  and  scholarly.    Parvin's  distinguished  position  as 

gleans  the  whole  field  of  obstetric  literature,  giv-  a   teacher,    his    scholarly   attainments,    and    his 

ing  the  reader  the  winnowed  wheat  in  concise  and  honest  endeavor  to  do  his  best  by  both  tne  student 

well-jointed  phra.se.  in  language   of  exceptional  and  the  physician,  will    secure  for  his  treatise 

purity  and  strength.    The    arrangement  of  the  favorable  recognition. — American  Journal  of  Obstet- 

matter  of  this  work  is  unique   and  exceedingly  |  rtes,  May,  1887. 


BARimSy  BOBEBT,  M,  2>.,   and   FANCOVBT,  M.  2)., 

Phys.  to  the  General  Lying-in  Uosp.,  Lond.  Obstetric  Phys.  to  St.  Thomas'  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.  In  one  handsome  octavo  volume  of  872  pages,  with  231  illus- 
trations.   Cloth,  $5 ;  leather,  $6. 


The  immediate  purpose  of  the  work  is  to  furnish 
a  handbook  of  obstetric  medicine  and  surgery 
for  the  use  of  the  student  and  practitioner.  It  is 
not  an  exaggeration  to  say  of  "the  book  that  it  is 
the  best  treatise  in  the  English  language  yet 
published,  and  this  will  not  be  a  surprise  to  those 
who  are  acquainted  with  the  work  of  the  elder 
Barnes.     Every  practitioner  who  desires  to  have 


the  best  obstetrical  opinions  of  the  time  in  a 
readily  accessible  and  condensed  form,  ought  to 
own  a  copy  of  the  book. — Journal  of  the  American 
Mrdical  Association,  June  12, 1880. 

The  Authors  have  made  a  text-book  which  is  in 
every  way  quite  worthy  to  take  a  place  beside  the 
best  treatises  of  the  period. — New  York  Medical 
Journal,  July  2, 1887. 


rZATFAIB,  W.  S,,  M.  JD,,  F.  B,  C.  P., 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  New  (fifth) 
American,  from  the  seventh  English  edition.  Edited,  with  additions,  by  Robert  P.  Har- 
Bis,  M.  D.  In  one  handsome  octavo  volume  of  about  700  pages,  with  3  plates  and  about 
200  engravings.     Inpresa. 

A  notice  of  the  previous  edition  is  appended. 


Students  and  practitioners  alike  have  already 
found  out  the  advantage  of  possessing  a  work  em- 
bodying all  the  recent  advances  in  the  science 
and  practice  of  midwifery.  It  has  deservedly  be- 
come a  standard  treati.se  upon  the  subject.  The 
Author  has  endeavored  to  dwell  especially  on  the 
practical  part  of  the  subject,  so  as  to  make  the 
work  a  useful  guide  in  this  most  anxious  and  re- 


snonsible  branch  of  the  profession.  At  the  same 
time,  the  purely  theoreti^cal  portion  has  not  been 
neglected.  Dr.  Playfair's  treatise  may  fairly  be 
sai^  to  represent  the  modern  school  of  teaching. 
It  Is  a  well-arranged  and  carefully  digested 
epitome  of  the  science  and  practice  of  midwifery 
which  has  greatly  contributed  to  the  advancement 
of  the  atndy.— British  Medical  Journal,  Jan.  3, 1886. 


KING,  A,  F.  A,,  M,  I>., 

Professor  of  Obstetrics  and  Diseases  of  Women  tn  the  Medical  Department  of  the  Columbtnn  Univer- 
sity, Washington,  D.  C.,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     New  (third)  edition.     In  one  very  handsome  12mo. 
volume  of  376  page.s,  with  102  illustrations.     Cloth,  $2.25. 

This  little  manual,  certainly  the  best  of  its  kind,  I  bulky— it  is  concise.  The  chapters  are  divided  with 
fully  deserves  the  popularity  which  has  made  a  |  sub-headings,  which  aid  materially  in  the  finding 
third  edition  necessary.  Clear,  practical,  concise,  of  any  particular  subject,  and  the  definitions  are 
Its  teachings  are  so  fully  abreast  with  recent  ad-  clearand  explicit.  It  ftilftls  its  purpose  admirably, 
vances  in  obstetric  science  that  but  few  points  '  and  we  know  of  no  better  work  to  place  in  the  stu- 
can  be  criticised.— .dmerwian  Journal  of  Obstetrics,  i  dent's  hands.  The  illustrations  are  good.— i4rcA- 
March,  1887.  ivea  of  Gynecology,  January,  1887. 

This  volume  deserves  commendation.    It  is  not  | 


BABKFB,  FOBDYCF,  A,  M.,  M.  !>.,  XX.  D.  Edin,, 

Clinical  /"rofessor  of  Mulwiferi/  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical  OolUgt, 
New  York,  tlonorari/  Fellow  of  the  Obstetrical  Societies  of  London  and  Edinburgh,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.    In  one  handsome  12mo.  volume  of  about 
300  pages.     Preparing.  

PABBY,  JOH^  S.,  M,  !>., 

Obntetrieian  to  the  Phxlnrirtphin  Unspital,  Vice-President  of  the  Obitet.  Society  of  Philadelphui. 

Extra  -  Uterine  Pregnancy:  Its  Clinical  IlLstory,  DinpnosiH,  PrognoHis  and 
Treatment.     In  one  handsome  octavo  vohiine  of  272  pages.     Cloth,  $2.50. 


TANNER  ON  PREGNANCY.    Octavo,  490  pages,  4  colored  plates,  16  cuts.    Cloth,  H.M. 


30 


Lea  Brothers  &  Co.'s  Publications — Jttidwfy.,  Dis.  Gliildn. 


LEISMMAN,  WILLIAM,  M,  2>., 

Regius  Professor  of  Midwifery  in  the  University  of  Olnsgcne,  etc. 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50 ;  very  handsome  half  Kussia,  raised  bands,  $6.00. 


The  author  is  broad  in  his  teachings,  and  dis- 
cusses briefly  the  comparative  anatomy  of  the  pel- 
vis and  the  mobility  of  the  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  study  of  the  pelvis,  while  in  the  third  the 
female  organs  of  generation  are  introduced. 
The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plain  aud  pleasing.  It  is  sufficient  to  state  that  in 
this,  the  last  edition  of  this  well-known  work,  every 
recent  advancement  in  this  field  has  been  brought 
forward. — Physician  and  Surgeon,  Jan.  1880. 

To  the  American  student  the  work   before  us 


must  prove  admirably  adapted.  Complete  in  all  Its 
parts,  essentially  modern  m  its  teachings,  and  with 
demonstrations  noted  for  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  as  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended. — N.  O. 
Med.  and  Surg.  Journ.,  March.  1880. 

It  has  been  well  and  carefully  written.  The 
views  of  the  author  are  broad  and  liberal,  and  in- 
dicate a  well-balanced  judgment  and  matured 
mind.  We  observe  no  spirit  of  dogmatism,  but 
the  earnest  teaching  of  the  thoughtful  observer 
and  lover  of  true  science.  Take  the  volume  as  a 
whole,  and  it  has  few  eqatilB.— Maryland  Medical 
Journal,  Feb.  1880. 


LANDIS,  MJENMT  G.,  A.  M.,  M.  D., 

Professor  of  Obstetrics  and  the  Diseases  of  Wometi  in  Starling  Medical  College,  Columbus,  O. 

The  Management  of  Labor,  and  of  the  Lying-in  Period.     In 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.     Cloth,  $1.75. 

The  author  has  designed  to  place  in  the  hands 
of  the  young  practitioner  a  book  in  which  he  can 
find  necessary  information  in  an  instant.  As  far 
as  we  can  see,  nothing  is  omitted.  The  advice  is 
sound,  and  the  proceedures  are  safe  and  practical. 
Centralblatt  fiir  Gynakologie,  December  4,  1886. 

This  is  a  booli  we  can  heartily  recommend, 
the  author  goes  much  more  practically  into  the 
details  of  the  management  of  labor  than  most 
text-books,  and  is  so  readable  throughout  as  to 


one 


tempt  any  one  who  should  happen  to  commence 
the  book  to  read  it  through.  The  author  pre- 
supposes a  theoretical  knowledge  of  obstetrics, 
and  has  consistently  excluded  from  this  little 
work  everything  that  is  not  of  practical  use  in  the 
lying-in  room.  We  think  that  if  it  is  as  widely 
read  as  it  deserves,  it  will  do  much  to  improve 
obstetric  practice  in  general. — New  Orleans  Medi- 
cal and  Surgical  Journal,  Mar.  1886. 


SMITH,  J.  LEWIS,  M.  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  T. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  New  (sixth) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  867 
pages,  with  40  illustrations.     Cloth,  $4.50 ;  leather,  $5.50  ;  half  Kussia,  $6.00. 

For  years  it  has  stood  high  in  the  confidence  of 
the  profession,  and  with  the  additions  and  alter- 
ations now  made  it  may  be  said  to  be  the  best 


book  in  the  language  on  the  subject  of  which  it 
treats.  An  examination  of  the  text  fully  sus- 
tains the  claims  made  in  the  preface,  that  "in 
preparing  the  sixth  edition  the  author  has  revised 
the  text  to  such  an  extent  that  a  considerable 
part  of  the  book  may  be  considered  new."  If  the 
voung  practitioner  proposes  to  place  in  his  library 
but  one  book  on  the  diseases  of  children,  we 
would  unhesitatingly  say,  let  that  book  be  the  one 
which  is  the  subject  of  this  notice. —  The  American 
Journal  of  the  Medical  Sciences,  April,  1886. 

No  better  work  on  children's  diseases  could  be 
placed  in  the  hands  of  the  student,  containing,  as 
it  does,  a  very  complete  account  of  the  symptoms 
and  pathology  of  the  diseases  of  early  life,  and 
possessing  the  further  advantage,  in  which  it 
stands  alone  amongst  other  works  on  its  subject, 
of  recommending  treatment  in  accordance  with 
the  most  recent  therapeutical  views. — British  and 
Foreign  Medico-Odrurgiral  Review. 

Those  familiar  with  former  editions  of  the  work 


will  readily  recognize  the  painstaking  with  which 
this  revision  has  been  made.  Many  of  the  articles 
have  been  entirely  rewritten.  The  whole  work  is 
enriched  with  a  research  and  reasoning  which 
plainly  show  that  the  author  has  spared  neither 
time  nor  labor  in  bringing  it  to  its  present  ap- 
proach towards  perfection.  The  extended  table  of 
contents  and  the  well-prepared  index  will  enable 
the  busy  practitioner  to  reach  readily  and  auickly 
for  reference  the  various  subjects  treated  or  in  the 
body  of  the  work,  and  even  those  who  are  familiar 
with  former  editions  will  find  the  improvements 
in  the  present  richly  worth  the  cost  of  the  work. — 
Atlanta  Medical  and  Surgical  Journal,  Dec.  1886. 

Dr.  Smith's  work  has  justly  become  the  standard 
all  over  the  world  as  the  book  on  children's  dis- 
eases. The  whole  book  is  admirable,  both  for  the 
practitioner  and  the  student.  Dr.  Smith  writes 
from  a  large  experience  and  a  close  observation 
of  cases  at  the  bedside.  He  is  extremely  prac- 
tical, and  these  facts  make  the  work  what  it  is — 
the  best  of  all  works  on  the  diseases  of  children. 
—  Virginia  Medical  Monthly,  June,  1886. 


OWEJSr,  EDMUKn,  M.  B.,  F,  M,  C.  S,, 

Surgeon  to  the  Children's  Hospital,  Oreat  Ormond  St.,  London. 

Surgical  Diseases  of  Children.  In  one  12mo.  volume  of  525  pages,  with  4 
ehromo-lithographic  plates  and  85  woodcuts.  Cloth,  $2.  See  Series  of  Clinical  Manuals, 
page  4. 


One  is  immediately  struck  on  reading  this  book 
with  its  agreeable  style  and  the  evidence  it  every- 
where presents  of  the  practical  familiarity  of  its 
author   with    his    subject.      The    book    may    be 


honestly  recommended  to  both  students  and 
practitioners.  It  is  full  of  sound  information, 
pleasantly  given. — Annals  of  Surgery,  May,  1886. 


WEST,  CHARLES,  M,  I)., 

Physician  to  the  Hospital  for  Sick  Children,  London,  etc. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood. 

12mo.  volume  of  127  pages.     Cloth,  $1.00. 


In  one  small 


WEST'S  LECTURES  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.    In  one  octavo  vol. 
CONDIE'S    PRACTICAL   TREATISE   ON    THE 


DISEASES  OF  CHILDREN.  Sixth  editioo,  re- 
vised and  augmented.  In  one  octavo  volume  of 
779  pages.    Cloth,  $5.25 ;  leather,  86.25. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  3Iiscel.  31 


TIDT,  CHAMLBS  METMOTT,  M.  B.,  F.  C,  S,, 

Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  etc. 

Legal  Medicine.  Voltime  II.  Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Rape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.  Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.     Cloth,  $6.00 ;  leather,  $7.00. 

Volume  I.  Containing  664  imperial  octavo  pages,  with  two  beautiful  colored 
plates.     Cloth,  $6.00 ;  leather,  $7.00. 

The  satisfaction  expressed  with  the  first  portion  '  tables  of  cases  appended  to  each  division  of  the 
of  this  work  is  in  no  wise  lessened  by  a  perusal  of  subject  must  have  cost  the  author  a  prodigious 
the  second  volume.  We  find  it  characterized  by  amount  of  labor  and  research,  but  they  constitute 
the  same  fulness  of  detail  and  clearness  of  ex-  one  of  the  most  valuable  features  of  the  book, 
pression  which  we  had  occa.sion  so  highly  to  com-  especially  for  reference  in  medico-legal  trials. — 
mend  in  our  former  notice,  and  which  render  it  so  American  Journal  of  the  Medical  Sciences,  April,  1884. 
Tftluable    to    the   medical    jurist.      The   copious  { 


TATLOB,  ALFRED  S.,  M,  D., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  tn  Ouy^s  Hospital,  London. 

A  Manual  of  Medical  Jurisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edited  by  John  J.  Reese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00 ;  leather,  $6.00 ;  half 
Russia,  raLsed  bands,  $6.50. 


The  American  editions  of  this  standard  manual 
have  for  a  long  time  laid  claim  to  the  attention  of 
the  profession  in  this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject 
to  which  he  devoted  his  life  with  an  assiduity  and 
success  which  made  him  Jacile  princeps  among 
English  writers  on  medical  jurisprudence.  Both 
the  author  and  the  book  have  made  a  mark  too 
deep  to  be  affected  by  criticism,  whether  it  be 
censure  or  praise.  In  this  case,  however,  we  should 


only  have  to  seek  for  laudatory  terma.— American 
Journal  of  the  Medical  Sciences,  Jan.  1881. 

This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  thirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  ia 
simplyindispensable  to  every  pnysician,  and  nearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26, 1881. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Medical  Jurisprudence.  Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations.  Cloth,  $10 ; 
leather,  $12. 


For  years  Dr.  Taylor  was  the  highest  authority 
In  England  upon  the  subject  to  which  he  gave 
especial  attention.  His  experience  was  vast,  his 
jaagment  excellent,  and  his  skill  beyond  cavil.  It 
IB  therefore  well  that  the  work  of  one  who,  as  Dr. 
Stevenson  says,  had  an  "enormous  grasp  of  all 


matters  connected  with  the  subject,"  should  be 
brought  up  to  the  present  day  and  continued  in 
its  authoritative  position.  To  accomplish  this  re- 
sult Dr.  Stevenson  has  subjected  it  to  most  careful 
editing,  bringing  it  well  up  to  the  times.— 4m«rv 
ean  Journal  of  the  Medical  Sciences,  Jan.  1884. 


By  the  Same  Author. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.  Third 
American,  from  the  third  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.     Cloth,  $5.50;  leather,  $6.50. 

:PEPPEB,  AUGUSTUS  J.,  M,  S,^M,  B,,  F.  R.  C,  S,, 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 

Forensic  Medicine.    In  one  pocket-size  12mo.  volume.    iVeparin^.    See  Student!^ 

Series  of  Manuah,  i)age  4. 

LEA,  HENRY  C, 

Superstition  and  Force :  Essays  on  The  Wager  of  Law.  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revi.sed  and  enlarged  edition.  In  one 
handsome  royal  l^mo.  volume  of  552  pages.     Cloth,  $2.50. 

should  not  be  most  carefully  studied  :  and  however 
well  versed  the  reader  may  be  in  ttio  science  of 
jurisprudence,  he  will  find  much  In  Mr.  Lea's  vol- 
ume of  which  he  was  previously  Ignorant  The 
book  Is  a  valuable  addition  to  the  literature  of  so- 
cial science. —  Wettv\\nat«r  Rtvieui,  Jan.  1880. 


ThJH  valuable  work  is  in  reality  a  history  of  clv- 
llisation  as  interpreted  by  the  progres-x  of  jurispru- 
dence. .  .  In  "Suiierstltion  and  For'-e"  we  have  a 
philosophic  survey  of  the  long  period  Intervening 
between  primitive  barl>arity  and  civilized  enlight- 
enment.   There  is  not  a  chapter  in  the  work  tnat 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 
efit of  Clergy — Excommunication.     New  edition.     In  one  very  liandsome  royal 
octavo  volume  of  605  pages.     Chith,  $2.50. 

Theauthor  is  pre-eminently  a  Hoholar.  lie  takes  I  primitive  church  traced  with  so  much  clearness, 
np  every  t<^)plc  allied  with  the  lea<ling  theme,  and  and  with  so  definile  a  perception  of  complex  or 
traces  It  out  to  the  minutett  detail  with  a  wealth     conflicting  sou rcfvt.     The  flfly  pa^es  on  the  growth 


of  knowledge  and  impartiality  of  treiitment  that 
compel  admiration.  Tin-  amount  ol  information 
compressed  Into  the  book  Is  extraordinary.  In  no 
other  single  volume  is  the  development  of  the 


of  the  papaov,  for  Instance,  are  admirable  for  con- 
olsenesH  and  freedom  from  prejudice. — Boston 
TVavellet,  May  3,  1H«3. 


Allen's  Anatomy  ....  6 

American  Journal  of  the  Medical  Sciences        .        3 

American  Systems  of  Gynecology  and  Obstetrics    27 
American  System  of  Practical  Medicine .  .       15 

An  American  System  of  Dentistry  .  .       24 

♦Ash  hurst's  Surgery     .  .  .  .  ,       20 

Ashwell  ou  Diseases  ofWomen       .  ,  .28 

Attfleld's  Chemistry      .....         9 

Ball  on  the  Rectum  and  Anus  .  .  .   4,  20 

Barker's  Obstetrical  and  Clinical  Essays,  .       29 

Barlow's  Practice  of  Medicine         .  ,  .17 

Barnes'  System  of  Obstetric  Medicine       .  .       29 

Bartholow  on  Electricity        ....       17 

Bartholow's  New  Remedies  and  their  Uses       .       11 
Basham  on  Renal  Diseases    ....       24 

Bell's  Comparative  Physiology  and  Anatomy  .    4,   7 
Bellamy's  Surgical  Anatomy  ...         6 

Billings'  Universal  Medical  Dictionary    .  .         4 

Blandford  on  Insanity  .  .  .  .19 

Bloxam's  Chemistry      .....         9 

♦Bristowe's  Practice  of  Medicine    .  .  ,       14 

Broadbent  on  the  Pulse  .  .  .  .    4, 18 

Browne  on  the  Ophthalmoscope     .  .  .       23 

Browne  on  the  Throat,  Nose  and  Ear       .  .       18 

Bruce's  Materia  Medica  and  Therapeutics         .       11 
Brunton's  Materia  Medica  and  Therapeutics     .       11 
♦Bryant's  Practice  of  Surgery  .  .  .       21 

♦Bumstead  and  Taylor  on  Venereal  Diseases    .       25 
•Burnett  on  the  Ear       .  .  .  .  .23 

Butlin  on  the  Tongue    .  .  .  .  .4,21 

Carpenter  on  the  tjse  and  Abuse  of  Alcohol      .         8 
•Carpenter's  Human  Physiology    ...         8 
Carter  &  Frost's  Ophthalmic  Surgery       .  .4,23 

Century  of  American  Medicine        .  .  .14 

Chambers  on  Diet  and  Regimen      .  .  .       17 

Chapman's  Human  Physiology       ...         8 
Charles'  Physiological  and  Pathological  Chem.       10 
Churchill  on  Puerperal  Fever  ...       28 

Clarke  and  Lock-wood's  Dissectors' Manual       .     4,6 
Classen's  Quantitative  Analysis      .  .  .       10 

Cleland's  Dissector        .  ....        6 

Clouston  on  Insanity    .  ....       19 

Clowes'  Practical  Chemistry  .  .  .10 

Coats'  Pathology  .  ,  ,  .  .13 

Cohen  on  the  "rhroat     .  ,  .  ,  .18 

Coleman's  Dental  Surgery     ....       24 

Condie  on  Diseases  of  Children        ...       30 
Cornil  on  Sj'philis  .  .  .  ,  .25 

Dslton  on  the  Circulation       ....        7 

♦Dalton's  HumanPhysiology  ...         8 

Davenport  on  Diseases  of  Women  .  ,  .       28 

Davis'  Clinical  Lectures  ...       17 

Draper's  Medical  Physics       ....         7 

Druitt's  Modern  Surgery         ....       20 

Duncan  on  Diseases  of  Women        .  .  .28 

•Dunglison's  Medical  Dictionary    ...         4 
Edes' Materia  Medica  and  Therapeutics  .       12 

Edis  on  Diseases  of  Women   ....       27 

Ellis' Demonstrations  of  Anatomy  .  .         i 

Emmet's  Gynaecology  .  .  .       28 

•Erichsen's  System  of  Surgery         .  ,  .21 

Farquharson's  Therapeutics  and  Mat.  Med.       .       12 
Fenwick's  Medical  Diagnosis  ...       16 

Finlaj'son's  Clinical  Diagnosis         .  ,  .16 

Flint  on  Auscultation  and  Percussion      .  .       18 

Flint  on  Phthisis  .  .  .  .  .18 

Flint  on  Respiratory  Organs  ...       18 

Flint  on  the  Heart         .....       18 

Flint's  Essays       ...  .  .       18 

•Flint's  Practice  of  Medicine  ...       14 

Folsom's  Laws  of  U.  S.  on  Custody  of  Insane    .       19 
Foster's  Physiology       .....         8 

•Fothergill's  Handbook  ol  Treatment     .  .       16 

Fownes'  Elementary  Chemistry      ...         9 
Fox  on  Diseases  of  the  Skin  ....       26 

Frankland  and  Japp's  Inorganic  Chemistry     .        9 
Fuller  on  the  Lungs  and  Air  Passages     .  .       18 

Galloway's  Analysis     .  .  .  .         8 

Glbney's  Orthopedic  Surgery  .  .  .20 

Gould's  Surgical  Diagnosis     .  .  .  .    4,  21 

•Gray's  Anatomy  .        .  .  .  .  .5 

Greene's  Medical  Chemistry  ....         9 

Green's  Pathology  and  Morbid  Anatomy  .       13 

Griffith's  Universal  Formulary       .  .  .11 

Gross  on  Foreign  Bodies  in  Air-Passages  .       18 

Gross  on  Impotence  and  Sterility    ...       25 
Gross  on  Urinary  Organs        ....       25 

•Gross' System  of  Surgery      .  .  .  .       20 

Habershon  on  the  Abdomen  .  .  .       16 

•Hamilton  on  Fractures  and  Dislocations  .       22 

Hamilton  on  Nervous  Diseases       .  .  .19 

Hartshorne's  Anatomy  and  Physiology  .  .         6 

Hartshorne's  Conspectus  of  the  Med.  Sciences  .        3 
Hartshorne's  Essentials  of  Medicine         .  .       14 

Hermann's  Experimental  Pharmacology  .       11 

Hill  on  Syphilis  ......       25 

Hilller's  Handbook  of  Skin  Diseases         .  .       26 

Hoblyn'K  Medical  Dictiorvary  ...         4 

Hodge  on  Women  .....       28 

Hodge's  Obstetrics        .....       28 

Hoffmann  and  Power's  Chemical  Analysis       .       10 
Holden's  Landmarks    .....         5 

Holland's  Medical  Notes  and  Reflections  .       17 

Holmes'  Principles  and  Practice  of  Surgery     .       22 
•Holmes'  System  of  Surgery  .  .  .22 

Horner's  Anatomy  and  Histology  .  .         6 

Hudson  on  Fever  ...        4 

Hutchinson  on  Syphilis  ....    4,2)5 

Hyde  on  the  Diseases  of  the  Skin    .  .  .       26 


Jones  (C.  Handfield)  on  Nervous  Disorders 

Juler's  Ophthalmic  Science  and  Practice 

King's  Manual  of  Obstetrics  . 

Klein's  Histology  .... 

Landis  on  Labor  .... 

La  Roche  on  Pneumonia,  Malaria,  etc.     . 

La  Roche  on  Yellow  Fever    . 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawsou  on  the  Eye,  Orbit  and  Eyelid 

Lea's  Studies  in  Church  History 

Lea's  Superstition  and  Force 

Lee  on  Syphilis 

Lehmann  s  Chemical  Physiology    . 

♦Leishman's  Midwifery 

Lucas  on  Diseases  of  the  Urethra   . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever   ..... 

Maisch's  Organic  Materia  Medica  . 

Marsh  on  the  Joints 

May  on  Diseases  of  Women  .  .  . 

Medical  News 

Medical  News  Visiting  List  . 

Medical  News  Physicians'  Ledger  . 

Meigs  on  Childbed  Fever 

Miller's  Practice  of  Surgery   . 

Miller's  Principles  of  Surgery 

Mitchell's  Nervous  Diseases  of  Women   , 

Morris  on  Diseases  of  the  Kidney  . 

Neill  and  Smith's  Compendium  of  Med.  8cl. 

Nettleship  on  Diseases  of  the  Eye  . 

Norris  and  Oliver  on  the  Eye 

Owen  on  Diseases  of  Children 

■"Parrish's  Practical  Pharmacy 

Parry  on  Extra-Uterine  Pregnancy 

Parvln's  Midwifery         .... 

Pavy  on  Digestion  and  Its  Disorders         . 

Payne's  General  Pathology    .  .  . 

Pepper's  System  of  Medicine 

Pepper's  Forensic  Medicine   . 

Pepper's  Surgical  Pathology 

Pick  on  Fractures  and  Dislocations 

Pirrie's  System  of  Surgery    . 

Playfair  on  Nerve  Prostration  and  Hysteria 

*Playlair's  Midwifery  . 

Politzer  on  the  Ear  and  its  Diseases 

Power's  Human  Physiology  . 

Purdy  on  Bright's  Disease  and  Allied  A  flections 

Ralfe's  Clinical  Chemistry 

Ramsbotham  on  Parturition 

Remsen's  Theoretical  Chemistry    . 

♦Reynolds'  System  of  Medicine 

Richardson's  Preventive  Medicine 

Roberts  on  Urinary  Diseases  .  . 

Roberts'  Compend  of  Anatomy 

Roberts'  Principles  and  Practice  of  Surgery 

Robertson's  Physiological  Physics  . 

Ross  on  Nervous  Diseases 

Savage  on  Insanity,  including  Hysteria  , 

Schiiier's  Essentials  of  Histology, 

Schreiber  on  Massage   . 

Seller  on  the  Throat,  Nose  and  Naso-Pharynx 

Semi's  Surgical  Bacteriology  .  . 

Series  ot  Clinical  Manuals 

Simon's  Manual  of  Chemistry 

Skey's  Operative  Surgery 

Blade  on  Diphtheria      .... 

Smith  (Edward)  on  Consumption   . 

*Smith  (J.  Lewis)  on  Children 

Smith's  Operative  Surgery     . 

Stllte  on  Cholera  .... 

*8till6  &  Maisch's  National  Dispensatory 

*StI116's  Therapeutics  and  Materia  Medica 

Stimson  on  Fractures  and  Dislocations 

Stimson's  Operative  Surgery 

Students' Series  of  Manuals  . 

Sturges'  Clinical  Medicine 

Tail's  Diseases  of  Women  and  Abdom.  Surgery 

Tanner  on  Signs  and  Diseases  of  Pregnancy 

Tanner's  Manual  of  Clinical  Medicine     . 

Taylor's  Atlas  of  Venereal  and  Skin  Diseases 

Taylor  on  Venereal  Diseases 

Taylor  on  Poisons  .... 

♦Taylor's  Medical  Jurisprudence    . 

Taylor's  Prin.  and  Prac.  of  Med.  Jurisprudence 

*Thomas  on  Diseases  of  Women     . 

Thompson  on  Stricture 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine .... 

Tocid  on  Acute  Diseases 

Treves'  Manual  of  Surgery    .  . 

Treves'  Surgical  Applied  Anatomy 

Treves  on  Intestinal  Obstruction     . 

Tuke  on  the  Influence  of  Mind  on  the  Body 

Vaughaii  &  Novy's  Ptomaines  and  Leucomalnes 

Visiting  List,  The  Medical  News     . 

Walslie  on  the  Heart    .... 

Watson's  Practice  of  Physic  . 

*Wellson  theEye         .... 

West  on  Diseases  of  Childhood 

West  on  Diseases  of  Women 

West  on  Nervous  Disorders  in  Childhood 

Williams  on  Consumption 

Wilson's  IlandVwok  of  Cutaneous  Medicine 

Wilson's  Human  Anatomy   . 

Winckel  on  Pathol,  and  Treatment  of  Childbed 

Wfthler's  Organic  Chemistry 

Wood  head's  Practical  Pathology    . 

Year-Books  of  Treatment  for  1886, 1887  and  1889, 


19 
23 
29 

4,13 
30 
18 
14 
23 
23 
31 
31 
25 
8 
80 

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17 
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Books  marked  *  are  also  bound  in  half  Russia. 


LEA    BROTHERS    &   CO.,    Philadelphia. 


mTK  ?HOP£Ki . 


